The Procedural Teaching Series: Endotracheal Intubation

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The Pre-brief

My initial title for this post was “How to watch your learner intubate without snatching the blade and tube from their hands and doing it yourself,” but that was a little wordy.

Teaching learners how to intubate patients is always challenging. Often, we don’t spend enough one-on-one time with each learner to feel confident that we know where they are in their procedural competency, and intubation is a high-stakes procedure. It’s also a procedure that, depending on the chosen mode of intubating, we can’t actually see them doing, and this makes it particularly hard to help guide them.

The easiest solution if the resident doesn’t immediately, confidently slide an ETT into the patient’s trachea is to grab all the tools, hip check them to the side, and take care of business yourself. But let’s say for the sake of argument that you’re a medical educator and you’re able to restrain yourself for the good of the learner. And so you compose yourself and say what every attending physician since the dawn of time has said to the resident in front of them trying to intubate… “What do you see?”

Since what the resident is actually thinking in that moment is, “Well, I don’t know, a bunch of soft tissue and saliva, thanks for asking,” I’d like to suggest some alternative techniques to help teach your resident to be successful at intubating patients.

Review your plan before giving meds 

Of course, some airways are crash intubations and there’s not always time, but typically even in sick patients, there are a few minutes while the nurse is pulling up medications that you’re prepping for the intubation. While that’s happening, discuss your airway plan, including what their first-, second-, and third-line techniques will be. This ensures that everyone is on the same page with what the plan is, and allows you to be ready to help them with each step. As a bonus, it also helps to ensure that the resident actually has a plan!

Take a pause

However stressed you’re feeling about how long the resident is taking to intubate, just remember they are exponentially MORE stressed and panicked. Asking what they see, or repeatedly announcing the gradual drop in pulse ox on the monitor is not helpful to your learner! When you feel the urge to say something, PAUSE for just a moment and give the resident just another few seconds to either ask for help or, miracle of miracles, successfully intubate the patient. This silence actually communicates to the resident that you trust them, and decreases the amount of ambient noise they are trying to process.

Ask what you can do to help

This is the exact wording I use: “What can I do to help you right now?” This allows them to proactively communicate any problems they’re having, such as, “I see the epiglottis but I can’t see the cords” or, “There’s too much saliva for me to get a good view.” From there, you can offer suggestions or solutions for whatever problem they’re having, rather than adding pressure to an already stressful situation for the learner. This technique also teaches them to identify and name the issue they’re having, as opposed to, “I don’t know, it was just a hard airway.” When debriefing after the intubation, make sure to circle back to what they themselves identified as a challenge during the procedure for even more learning opportunities!

The Debrief

Of course, sometimes you’re going to just activate your snatching hands and take over that airway if it’s the right thing for the patient, but by reviewing your plantaking a pause, and asking what you can do to help, you can help your resident become more confident and successful when intubating while simultaneously building trust with your learner and team.

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