I get called to do intubations all over XYZ Hospital. Impending respiratory failure and airway protection are usually the two biggest reasons for inserting endotracheal tubes in patients. Very often, when I arrive at the patient’s bedside, I am met by:

1. a first year intern
2. a fourth year medical student
3. an ER or ICU resident
4. an EMS student

with an eager, wide-eyed, hungry look on their face. I’m familiar with the look; it’s the first eye contact that is made with me as I arrive carrying my code box, and the greeting and exchange of information is always the same….Hi, are you anesthesia? I’m ….. and this patient is not doing well and will need an endotracheal intubation. (here it comes….)  Would it be alright if I put the tube in?  

Therein lies the quandary. So Let’s Talk a Little Bit about the surrounding conditions that anesthesia providers find themselves in when intubating the trachea.

In the OR, for all elective cases, the patient is NPO. Bed height is easily adjustable; working suction within arm’s reach; and every intubating tool, device, and medication, in addition to extra anesthesia personnel, is at hand. There are different sized masks and types of airways, and the anesthesia ventilator is at the patient’s side. This is a controlled environment, which is always optimal for successful intubations.

Contrast this with an emergent, urgent, or semi-urgent intubation elsewhere in the hospital. PO intake status is unknown or questionable; suction may either be not ready or of dubious strength; all tools, devices, and personnel to assist with intubation are not always present and accounted for, properly functioning, or adequately experienced. It’s a jungle out there!

Add to this mix the ubiquitous unknown factors - how difficult will this patient’s airway be, and how will this patient respond to manipulation of the airway? Taking in the big picture, these are all less than optimal conditions for intubation. But intubation has determined to be necessary, and so we must act in the patient’s best interests.

The approach taken to any intubation must always be carefully thought out and well planned, and must always include a weighted strategy, not just forging ahead and trying to put the tube in…… what to do if it looks like a difficult intubation?…what to do if you cannot intubate?…cannot ventilate?

The responsibility for the patient’s airway rests with the anesthesia provider who has been called to the bedside. This is why the intubation is not always so readily handed over to an apprentice or even someone with a little more experience. I may be meeting you at the bedside for the very first time, and I have no idea what your training, skills, and comfort level with intubating may be. How adept and careful are you? If you should knock out a tooth or injure the cords while intubating, that is my fault. If you goose the patient (anesthesia lingo for intubating the esophagus), then every subsequent laryngoscopy will view a slightly more edematous or quite possibly even bloody airway as a result of repeat manipulations. Do you think that could be risky?

I enjoy teaching and mentoring, don’t get me wrong. Some patients have great airways to learn on; others have great airways to learn from. But I believe that all patients needing intubation must be approached from a safety first standpoint.

If you are turned down for the chance at an intubation at the bedside, please don’t take it personally or get mad at the anesthesia provider. Understand that it can be a multi-faceted situation in a multi-factorial decision tree. Not all intubations are created equal.

If you are interested in honing your intubation skills, why not consider a rotation in the OR, shadowing an anesthesia practitioner, for a week or more? We love to instruct, and you’ll get much more optimal exposure to putting the tube in, too.

Thanks for reading.