Just Pass the Tube: The Value of an Anesthesia Rotation

Opinion:

Ryan Lucas, OMS-IV, Rocky Vista University College of Osteopathic Medicine
EMRA MSC Osteopathic Coordinator

“You have ten seconds to pass this tube.” My attending’s words were immediately followed by a wave of anxiety and adrenaline rushing over me. The patient was a healthy, twenty-something with a normal BMI who was undergoing a routine hernia repair. This was now my fourth week of my elective anesthesia rotation and the intubation should have been easy.

I went through the stepwise approach to intubation that I had been dialing in over the past four weeks: position the head, scissor open the mouth, insert the blade, sweep the tongue, advance, lift up and out, see the cords, pass the tube. The first seven steps went smoothly, it was the eighth and final step where I encountered issues. With a clear view of the glottis in sight, I could not pass the tube.

First, the tube was getting caught on the patient’s molars. After some adjustment and one obstacle overcome, the cuff was now hung up on the arytenoids. I felt my heart rate increase as beads of sweat emerged from my forehead and my goggles began to fog. “What do you see?” I pulled the tube back, rotated it some, and tried to advance again. “TELL US WHAT YOU SEE!” I tried once more. “Okay, that’s it. Move aside!”

I watched as the resident withdrew a bloody endotracheal tube from the patient’s mouth, quickly reset, and successfully intubated the patient within about five seconds. My attending was livid. “You messed up! You injured the patient. You should never have to try that hard or that long without passing it on to someone with more experience.”

Prior to this attempt, I had successfully intubated almost every patient for the past three weeks. I had come a long way from my first week where I clumsily attempted to scissor open patients’ mouths and barely left enough room to insert the laryngoscope blade. I had found the correct combination of patient positioning, body mechanics, and force necessary to obtain an adequate view of the glottis for most patients. I had picked up tips and tricks to make passing the tube easier. Today, however, I felt the pressure of my attending’s words and my process broke down.

My experience in medical school has been mostly working one-on-one with attendings or a small group of residents. Procedures have largely been done with a single supervisor or minimal supervision at all. I’ve been allowed to take my time. No patients are harmed by a clumsy presentation. If a stitch doesn’t look good, just take it out and throw another. Intubation is not like other things we learn in medical school.

Once the paralytics are pushed, there is a finite amount of time before the tube needs to be passed and the patient placed on the ventilator. The eyes of the room are upon you: the OR nurse, the scrub tech, the surgeons, residents, other students. Everything comes to a standstill as they wait for you to pass the tube so everyone can proceed with their respective tasks. Any feedback, positive or negative, from your preceptor is on full display to the room. “Off the teeth!” is a frequent reminder. “What do you see? Talk to me.” Let us not forget the most dreaded feedback of all: “You’re in the esophagus.”

I fumbled and stumbled my way through several days, missing almost every intubation attempt (and tubing several esophaguses), before I finally found a system that worked for me. In quick, elective procedures, the OR turnover is rapid and the intubation chances are frequent. Stepping up to intubate the next patient after your last attempt failed is intimidating. Although everyone in the room remembers your last failed attempt, your memory has to be very short. After my bloody failure, I intubated the next patient without incident and got a “much better, good job” from a now cooled down attending.

Outside of dedicated emergency medicine rotations, this anesthesia experience was one of my most formative. Much like the OR, the ER requires a team. Sometimes the team is big. The eyes of the room are upon you. Things will go wrong. As future emergency medicine residents, we will need to develop systems for many processes and procedures requiring many repetitions. When things do go wrong, we have to find where our system broke down, keep our memories short, and simply be better the next time. A month spent at the head of the bed was a humbling reminder for me and I highly recommend it to any student considering a career in emergency medicine.