There are a few people that lay claim to the airway in medicine. EM docs are a big one, and we usually spar with anesthesia. Paramedics handle tubes in the field in many systems, and then ICU docs are a third. Before my last airway, I had done anesthesia tubes, and ICU tubes, but the ED tube--that's a different ballgame. One of our lecturers calls it the 'super bowl' of airways.
When I heard that the first time, I thought it was a bit over the top, until I had a truly sick airway.
Sixty-something obese, small-jawed alcoholic with a bicarb of 3, Kussmall respirations, yet somehow still oriented, needs a tube. We positioned him ear to sternal notch as we were supposed to. First pass, and I saw cords but the mouth was tiny and I couldn't pass the tube. Terrible feeling. Someone holding pressure on the trachea was also less than ideal, moving it while I was looking--but still.
Bag with a nasal airway. Staff takes a look, 2nd pass with a bougie, tubes him blind and blood sprays out the tube all over (yay for gowns and masks!) and no color change. We place a King LT to bag him back up from the low nineties, which is not too bad, but he was dropping. "This is exciting", says my staff, who is a sharp, smart young doc we all love to work with.
Third staff comes in and looks, all smiles, like he's at the coffee shop chatting about donuts. Next pass, bougie again, downsize the blade to a 3 because the airway is anterior--always changing something, and this time bougie through cords visualized and the tube passes. More blood and no breath sounds on the left, so pull the tube back.
This was my first ED tube but not my first tube; a previous post talked about my anesthesia rotation where I was up to 13, then I had an ICU month with 6 and hit them all, so I was at 78% first pass success and about ten in a row on the trot, which is to say, nowhere near proficient, but not a total newbie. But this one was terrible. Sick, sick, sick. I see now why they call it the super bowl of airways. I see now why my attending said when I was setting up, 'got your bougie?', and 'got your King LT?' Up to 1% of ED airways are not tube-able. That's a lot. Many, many more are like this...badness. And it will go down as a procedure with no hypoxia, no hypotension, and no perceived adverse event.