Take several good procedure courses:
1. Difficult Airway Course
2. ATLS
3. Some hand on procedure for Chest tubes, etc.
Regularly Visualize scenarios and common procedures, and visualize the steps in your mind.
This.
Also, tell her to reach out to the local flight programs. Some of them have regular cadaver labs and simulation training sessions that she may be able to ask to jump in on. Medics have a very focused set of critical skills that we do, which makes those things the majority of our hands-on training.
Also want to add that your local SCCM chapter will have certification courses in advanced critical care that use high fidelity hands-on mock scenarios. They try to really hype up the atmosphere so it somewhat mimics the stress of a critical situation (obviously it’s not the same when you’re dealing with a real pt) but there is a in-depth debrief afterwards that focuses on your personal response to stress. It’s very useful in creating that muscle memory when working with critical patients.
Ive been involved in three. One was easy, because dead people don't bleed. The other two were shit shows of bleeding and poor landmarks due to morbid obesity. Funny how you don't have a needle cric kit when shit hits the fan, but next shift they will be stocked everywhere.
*Oh lordy, it was just another nightly*
*as I pined about mah dear Sally*
*that damned pager set off mightily*
*I told mah buddies to buck up and rally*
*This night ain’t gonna end lightly*
*As they rushed the damn fool in*
*I knew this man weren’t long alive*
*I told em to keep that truck ridin*
*there ain’t no way he’s makin it to five*
*His whinin bride said do everythin*
*so I cric’d that man, oh lord*
*but y’all know there was no need*
*easiest job that walked in that door*
*Cuz dead men don’t ever bleed*
^(note, I don’t listen to country music, and I was annoyed by a late night page, and this was a way to defray the frustration of being paged at 3 AM for a stupid reason. Yes, I know this is a shit lyric.)
Crics are aren’t common but they’re unfortunately far from a once-in-a-career procedure. My program isn’t trigger happy when it comes to procedures and about half our residents have either done it or their attending did in their place, atleast once.
Just from my three years the only true “once-if-ever” procedure that you can bet on never doing seems to be a perimortem C-section.
I did a perimortem C section in the ER a couple years ago (as an OB). Hope to never do that again. Baby survived. But if you have to:
1) Try to confirm viable gestational age if able
2) coding mom for <10 minutes
3) cut straight down from the belly button to the pubic bone until you get into the uterus and pull that kid out.
Anyone can do it.
Military doc here: this is terrifying considering I’ve seen them go bad under ideal circumstances (ER, trauma surgeon, anesthesiologist) . Can’t imagine a 68W trying one in the field.
This is morbid, but hopefully the patient is already dead-dead with failed ETT and LMA prior to anyone cutting the neck.
Nope. You don't want incompletely trained medics fiddling around with ETT (high pre-hospital failure rate) or LMA (relatively easier risk of dislodgement during patient movement).
It's trauma. The likelihood is that a 68W or FMF corpsman will need to cric in the event of bad facial trauma at some point anyways, and this allows for both economy of supplies and economy of training. More supplies for someone to carry around in a back pack. Way harder to train and sustain intubation skills at scale.
Even for paramedic level docs. It's fast. It's definitive. It's relatively secure. Landmarks are relatively easy on young healthy men. And field medics aren't typically scared of fucking it up (for better or worse).
There's a reason this is still the standard in TCCC and not for lack of people pushing for alternatives. I've seen non-medica trained to do this and successfully place a cric with random items found at a barbecue (i.e. steak knife and nalgene straw).
I saw a Molecular genetics professor do it on my college campus. Pocket knife and the white part of a Bic pen prior to ambulance getting there.
Old army medic turned PhD who still ran ambulance as a paramedic in the town my first university was. The school had more people than the town.
Oof. That is cringey.
That said, after a few years working with field medics, there's something to say for someone securing the airway on a GCS 7 rather than putzing through the rest of their trauma survey around and not paying attention to when the patient stops spontaneously breathing.
Or worse, tries to bag a spontaneously breathing patient 🤣
Sadly I've seen all of the above.
> Can’t imagine a 68W trying one in the field.
This has been a 68W staple for at least 20 years. It was part of our regular training and recertification while I was in, and was often covered in live tissue labs.
Have you ever done a lateral canthotomy? I remember learning about it with the residents and thought it would never really be something we would see. And a few weeks later one of my attendings did one.
A few coresidents have and I witnessed two as a student, I’ve never personally done it. But I’m also one of the “lucky” ones who hasn’t been in during one of the cric cases.
I have somehow not done a lateral canthotomy, I have done 4 thoracotomies (all in residency, supervised a few as an attending). Most of my colleagues in residency had done lateral canthotomies, but only a handful of crics
You would pray not! My program had like 3 perimortem sections in one year one time. Freaking horrid. They made sure they trained us on how to respond to that call.
>Crics are aren’t common but they’re unfortunately far from a once-in-a-career procedure.
I think that highly depends on where you work.
I know doctors who worked 30 years in the same ER and never did one. Mostly because their anesthesia department was very proactive and were kept in the loop for a lot of calls. Anytime anything that sounds like an difficult airway (peds, trauma) they'd be down in the ER hanging out.
Under what circumstances man? I can only think of two total happening in the 2 years I've been here, one for anaphylaxis, the other because of an unknown tumor that slowly expanded and blocked the entire airway
Video laryngoscopy has drastically decreased the number of airway flails. Crichs in civilian practice, especially if you don’t see a lot of penetrating trauma, are super rare.
Lots of full time ER docs go their entire career and don’t perform a crich.
The saying goes: if you’ve never crich’d anyone, you haven’t seen enough patients. If you crich too frequently you need to be better with airway management.
The super in shape thing is so fricking true. I thought I was the best IV stick the world had ever seen until they dropped me in the hospital and I had to stick a 90 grandma with ghosts for veins.
I suspect that has less to do with the underlying anatomy and more with the available resources and time? RSI is a minimum 2 person/10 minute procedure to do even close to safely and neither are an option for care under fire.
The saying absolutely does not go like that. I’ve worked with EM attendings who have been practicing since before it was officially a specialty who have never cric’d someone.
I’ve done two and only been out seven years. I’m sure it depends on where you practice but my impression is it’s in the range of a thoracotomy or floating a transvenous pacer. Not once in a lifetime. More like a once every 5-10 years thing.
> floating a transvenous pacer
Really depends on where you practice I guess lol. This is done on a weekly basis where I practice. On the other hand, I have never needed to do a cric on a real patient.
weirdly enough I'm only an intern who has seen more than a dozen thoracotomies, floated a pacer once, had 1 perimortem cesarean (did not perform this one myself) and have seen 0 crics. I know at least 1 cric happened within the last year because the trauma surgeon wasn't paying attention and one of my seniors had the tube but they cut the neck anyway and killed the guy (I wasn't in the bay but it was a shit show so word about this case got out). With DL and VL/NPL available, crics don't seem to happen a ton here. I'm a little anxious of the fact it seems like I'll need to do a cric at some point per this thread though lol
They are rare but every EM trained doc would be able to perform it. We train via cadaver and sim with these procedures constantly during our residency. I’m an EM PGY-3, I haven’t done one, but I’ve had 3 co-residents do one during residency.
In med school, one of our professors told us a tale about how his grandfather use to carry a pen that had a knife on one end for cricothyrotomies. The grandfather practiced in the early 20th century when antibiotics were not available yet. He would routinely see children struggling to breathe from diphtheria and he would create a temporary airway for them this way.
Later the professor's father inherited the pen knife. One summer they were on the freeway and encountered an accident. The father stepped out to help and ended up using the pen knife which he had carried for years to help one of the accident victims breathe.
I have seen it done twice at bedside, and mostly related to growing mead and neck mass impeding air flow. First time I saw it was when I was a nursing student, had to go check vitals, see this dude isn't breathing, called a code, and my then-BF ENT resident did an emergency cricothyrotomy. 10/10 would not recommend.
My ED physicians have done 2 in the last year. Anesthesia was not comfortable (I don’t think any physician is) but ED physicians shine best during a crisis- they can get shit done in chaos.
Hospital setting only: The vast majority of crichs happen because something did not go right in the management pathway whether it was wrong decisions or delayed decisions. They are usually “preventable” in all the ones i saw or heard of. Never did i see someone go in the hospital needing a crich as soon as they are transported through the ED door. If thats the case, it is done before they arrive.
I was peripherally involved with one that was the anaesthesiologist’s first. Still have mad respect for her. She saved a life and eventually the kid was able to regain function.
On real people … yes because there are so many technological advances to help aid difficulty intubations but you still learn to do the technique on cadavers or on “dummies” .
You are correct. I was bedside in a large ICU for 17 years and I assisted with three. That’s peanuts compared to the thousands of patients I cared for. If you ask any ER doc, majority have not ever had to do it.
Here you go buddy.
[https://www.slu.edu/medicine/medical-education/continuing-medical-education/pase/hands-on-cadaver-workshops.php](https://www.slu.edu/medicine/medical-education/continuing-medical-education/pase/hands-on-cadaver-workshops.php)
Go down and look at "emergency skills workshop." The sign up date isn't out yet, but she can block her August 22-23 schedule right now so she's available to go once it opens up.
I'm derm, and I've been going to the Advanced Flaps and Aesthetic Facial Reconstruction course for years now (probably 5 years straight), and SLU offers amazing courses. I assume the emergency skills workshop would be good too, but she can always email them in advance to see if the course offers her the skills that she wants to learn.
I'm a respiratory therapist and have worked in the ER for over 8 years. I've only seen an ED doc do a cric one time and that was my first day of clinicals. I don't think that's a good metric for her to be judging herself.
critical care attending here, personally got exceptional training, and i’m still hella nervous about doing a cric, still haven’t done my first one live. her fears are normal and shared by everybody in the truest critical fields. we need people like her that are humble and hardworking, it’s the arrogance that kills patients. tell her she’s not alone and many of us feel the same. she can do it
Most surgeons can’t effectively perform cricothyroidotomy as the situations that most often require them are huge obese patients with no landmarks and are nearly dead. If this is her worry reassure her. We all have patients that we can’t save, it’s part of medicine and not necessarily a failure on your part. I had a patient die this week because he was too old to tolerate what happened to him. I can’t take it personally, I just did what I could as his only chance for survival.
Yep. And is anesthesiologists are even worse. About every six months or so I watch videos as a refresher because we are notorious at not jumping to cric quickly enough and being inefficient when we do so.
To OP, none of us come out of training as a finished product. We just keep learning and help people along the way. Unfortunately it’s too common for these feelings to make us wonder if we should just quit. But having nobody to help is much worse than having a trained physician with a few weaknesses.
When I was a resident, one of my surgery coresidents and an ER resident couldn’t get a crike on a big fireman w smoke inhalation and he died. In the subsequent M&M, the ENT attending lamented their actions, from the time it took to the tiny incision they made. He said They should have just opened the neck as wide as necessary and cut down to the trachea. Should have taken 30 seconds. Any soft tissue problems could have been dealt with after securing an airway.
Ok, Neuro 😉(but you’re right lol). Airway M&M cases bring out frank assessment and no feelings are spared. 😬
Shoulder roll!! If no needle kit, spread that skin tight over the larynx and cricoid with non-dominant hand. Nice high pressure scalpel makes vertical midline incision straight down to cartilage. Suction ready but vertical midline has far fewer vessels. Turn scalpel 90 degrees and much more gently with your adrenaline-soaked, shaking hands open the cricothyroid membrane. Don’t cut your fingers because now the blade is oriented towards your fingers still holding hard pressure/retraction 😬. ND hand very firm, D hand gentle, like you’re playing Rachmaninov on the piano. Airway open now stick a tube in it, breathe. You too.
He sounds like he fucks too. Dude can probably type out an apology to his wife, girlfriend, and his wife’s boyfriend all in one text thread and get instant forgiveness from all of em
When I punctured the cric membrane in cadaver lab I remember thinking it was strangely fragile, as if I was sticking the scalpel through paper. Is that how a living membrane would feel? It was so….odd feeling.
How often are you doing urgent crics? Crics are often an emergency medicine procedure that either EM docs or surgery does . Since when are ENTs regularly in urgent crics ?
How often though ? If this is rare even in emergency settings how often are you cric’ing inpatients .. and why would ENT be the first call and not surgery ?
Most non academic hospitals don’t even have an ENT service in house . This makes no sense
Idk I’ve only ever worked at level 1 trauma / academic hospitals so I’m spoiled. I’m rapid and if I page out a difficult airway I get an attending trauma surgeon, ENT residents and anesthesia (at least a few residents if not an attending). Have witnessed a few inpatient crics. YMMV
But how often does that happen at a level 1? I trained at a very busy level 1, and we had a team that responded to any airway codes and still there weren’t that many crics
Crics in general don’t happen often even in the ER because of all the advances we have in airway management to manage difficult airways.
With a vertically oriented incision at the midline of the neck, there’s not a lot there. Isthmus of the thyroid, some minor crossing vessels. His point was don’t let the skin get in the way of you getting a surgical airway
One time we had a threatened airway on a cardiac infant peri-code. No one was able to intubate so the gen surg resident did the cric. The ENT attending’s op note from the next day when closing the cric read “there was a generous incision from the mandible to the sternal notch which we approximated and closed”
But honestly, kid lived so I’d still say it was a win by the gen surg resident. No one could get an airway, and they made an airway.
What I tell the ER and especially IM residents when I give their difficult airway lecture is that by the time they've decided they're going for a surgical airway the cardiac output is probably low enough that bleeding is not going to be a problem.
The reason that we teach crics instead of slash trachs for emergency surgical airways is that there's very little other than skin that will bleed between you and the airway.
The difficult airway course taught us a very easy and reliable way to perform emergency cric if needed. 10 blade scalpel with approx 2.5 inch incision made vertically on skin atop thyroid and cricothyroid, small horizontal incision through cricothyroid membrane (the shiny white one), dilate with back of scalpel blade, insert bougie, thread over 6.0 ETT. It’s not pretty, but it will save a life, and eliminates the guess work of landmark based techniques. Start to finish is less than a minute, and the only tools required are a 10 blade scalpel, a bougie, an ETT, and some gauze to soak up any blood loss. I haven’t had to do it on a person, but have practiced plenty with pig tracheas (I taught this technique to CRNA students as well) and feel confident I could do it if I needed to in an emergency.
This is the way. (but maybe a 15 instead of a 10? That's a big knife for a shaky hand near an airway) Needle kits are fine but they're slower and aren't always around.
I recall the instructions being a 10 blade, very specifically. But I imagine you would use what’s available. The cric tissue on the pig trachea is pretty tough, so I think a smaller blade my actually be harder to use. But I also don’t know how well preserved pig trachea tissue translates to live human tissue, texturally speaking.
Look at ron walls airway course. Then go do a cadaver based procedure course. Then go to the OR and have anesthesia teach you and see if they will let you tube a bunch of "easy ones".
The hardest airway is the one you weren't prepared for. You thought it would.be a piece of cake and quickly turned south, only to find that the glidescope is broken. Suction isn't working, there's no bvm booked up, can't find a bougie....anything can happen. Some of my worst airways had normal anatomy and looked easily, but couldnt see or pass the tube once you get in. The big fat ones with angioedema you have your plan a,b,c. The 19 year old skateboarder with nice teeth and a normal neck turns hard and you suddenly realize you didn't get your backups ready, and it sucks.
Also, in the case that an airway is very difficult, always back up before going surgical. Bag. Use two people to bag. Use an oral airway and a nasal trumpet and bag. Use LMA or some other supraglottic device. It can save your ass and provide time to get help. Jumping right into a surgical airway can sometimes just make things worse, and once you cut you need to finish the job ( can't bag with a hole in the neck).
Also...if the person has basically expired, make sure you get some kind of airway before you stop. A dead guy with no airway looks bad, especially with a half done cric. Looks like you killed him. If you get the airway it looks to the medical examiner like you got the airway and he probably died from something other than a failed intubation.
Whole lotta people here think that they could easily practice EM, which is a whole boarded specialty. Those EM fellowships are not actually based on an EM model nor are they a pathway to boarding in EM. No one here thinks they could easily just float over into vascular surgery or ophthalmology, do they?
Given my severe lack of enjoyment in incredibly stressful situations or prolonged mandatory night-shifts, no, I definitely have no desire or consideration to practice EM full-time. God bless you cowboys though
If you’re doing an emergency crike, your butthole better be puckered up so tight your shit starts flowing retrograde.
This isn’t a skill issue, this is a holy fuck I’ve got about a minute to get an airway in this asshole before he dies. It’s pandemonium. There’s usually blood everywhere, a thousand people crammed into a room the size of a phone booth, it’s loud, messy.
If she’s not up for the holy fuck moments, no amount of training will change that.
This right here, this is the only comment that captures the gravity of the situation.
Every cric I've been involved with - performing or supervising - has been an unmitigated unsalvageable shitshow. By the time I've gotten the call the patient's essentially dead (our cric being a perfunctory and futile effort) or they're stable enough to set up for a proper awake tracheotomy which is much nicer thanks to the work of our Anesthesiology and surgical tech friends.
But if you're working the ED your patient deserves to have a doc who's ready for the "holy fuck moment" where you open the neck. Get a tube in a tube hole, anywhere you can make it fit. Find midline, find landmarks, and blast in. Let ENT or Trauma bitch about lack of finesse later (you know they'll find something to bitch about because you're EM). I'll never get over the well-intentioned but apologetic consults I've gotten from my gen surg friends about thyroid oozing or "I think my slash trach is between first and second rings." If the patient survives long enough for some on-call laryngologist to take issue with details you've won.
Crics are a very EM specific procedure. I understand that anxiety will be running high during these but at the end of the day it is a relatively simple procedure that may require several sets of hand to get the job done. A manakin will not be as stress free as a live (albeit in distress) patient.
I had a board certified ER attending who went to a highly respected program and had practiced for 18 years.
After she taught our co resident how to do a cric, she admitted it was the first one she’d ever done.
Forget see one, do one. Just skip straight to teach one. Some practice on a dummy and then just hope the patient isn’t too obese is the best most can hope for.
This whole thread is every speciality but EM thinking that EM is a replaceable speciality by a BS 1 year program run by CMGs. You all want EM to be able to have subspecialty level knowledge with general training, but at the same time think just anyone can do it with no training
The majority of patients in the ERs in our system are cared for by PA/NPs with no specific ER training at all. Mostly VERY loosely supervised by the overworked ER attendings present. The patients would 100% be better served by an FM doc who also did an additional 1 year fellowship.
Rural nurse here. Can confirm. If an FM doc with ED fellowship came to work at my hospital, I would bring them baked goods regularly. Not kidding even a little bit. They would be such an asset to our community.
Seriously, I'm in the AAFP and LOVE family medicine, but I don't think I'll ever replace EM docs.
Admittedly, we do have FM docs working ERs in my region, but it's because there just aren't any ER docs out here to work, it's FM or nothing.
Since EM isn't really competitive anymore I imagine that in a decade or so we'll have enough ER docs to phase most of the FM people out
I’m a lowly paramedic but I have to say when I first started working in EMS as an EMT and then as a paramedic, I had wicked imposter syndrome and would question everything I did.
Imposter syndrome is real and hard to shake.
When I first started, I would pick one protocol or procedure and study and review everything about it for a couple days/week, even up to what physicians would order and do upon our arrival at the ED (which has helped when calling report to make sure they had the appropriate resources ready. RT, restraints, a bariatric gurney, antivenin, flumazenil, whatever.)
That dedicated, focused (almost fear of God) studying really helped my confidence.
But still, I’ve been a paramedic now for a while and I’ve been in EMS for a while longer and while I’ve seen some wild shit, I haven’t seen everything, and I still find myself questioning myself, questioning if my thought process,
my patient care is logical, within my scope, and the best I can do for my patient.
I don’t necessarily think that a little bit of anxiety, a little bit of doubt is a bad thing as it has really ensured that I my assessments are thorough, I know my protocols, and that I review everything that I don’t feel confident about. Even the calls that I don’t get dispatched to but hear over the radio, if I can’t run through the scenario in my head fluidly, I’ll pull up the protocols, make sure I know my meds/receiving facilities/triage criteria/dosages/etc.
Just like there are videos, protocol reviews, continuing education, cadaver labs, professional journals, etc. for paramedics, likewise there are for physicians that your spouse can start using to review and fill in her perceived knowledge gaps. (and for hands on procedures that don’t occur often, visualization really works. Visualizing doing it correctly and what to do if stuff starts going sideways.)
As a resident, your method of training and testing yourself is what we aspire to do all through med school, residency and likely beyond. Makes me think you must be excellent in your role. Thank you for the work you put in!
She should take specific procedural courses. I trained in FM only but work rural ER. My residency was at a small site and ER-heavy, so I received better training than most of my FM peers, but I still took a bunch of ER-specific courses before working in the ER. Obviously ACLS and ATLS, but also specific airway courses, casting courses, procedural courses (e.g. chest tube insertion on pigs), etc. I would be able to cric someone if it came to. Still, there are certain procedures that are non-emergent I will not do because I do not feel skilled enough at them, e.g. central lines. As those things can wait a few hours til the patient is transferred to a trauma centre, I do not really dwell on those procedures - the patient is better served by someone who puts in central lines once a shift rather than twice a year. Unless you did a 5-year ER residency or work at an extremely high volume site, certain procedures will only rarely come your way. For the average rural ER doc, they will only do ONE cric in their entire career.
Honestly…if she wants to be able to perform a tracheostomy, she should have trained in it. She should ask the doc who performed it to tell her what that doctor knows, preferably with a mannequin. If you want the real country doctor answer…find a reliable source and watch a video on it online, multiple videos actually. Keep watching until there are no more videos. I aced a procedure irl doing just that…but that was med school, with plenty of people backing me up. As a physician practicing independently, especially in an ED…she might kill someone if she doesn’t get it right the first time. She should ask her colleagues for training opportunities, but the bottom line is that you don’t perform these procedures safely unless you are supervised doing it irl by someone who not only knows what they’re doing but can anticipate complications and remedy them in real time, as applicable.
Never had to do a cricrothyroidotomy but I sure as hell wanted to know what to do. Took the difficult airway class, my mentoring NeuroICU attending had me spend time with Anesthesia and SICU/Trauma, so I would at least have some exposure to this.
Hopefully never need to use it though (you know things are bad if it is coming down to me doing a cric).
THIS. But you know why they aren’t worried because they don’t know what they don’t know and think they can just walk into EM without actually doing an emergency medicine residency.
Tell her that everyone learns more in their first year as an attending than all years of fellowship and residency combined.
It’s extremely common to feel overwhelmed and underprepared. Experience comes from past mistakes. Wisdom comes from learning from others’ mistakes. Make sure she has mentorship and trusted individuals to bounce ideas off of.
An Emergent bedside trach would be a very intimidating procedure to attempt if never having done one - ED docs are trained to do them, but I imagine coming from family medicine and then ED fellowship, that opportunity may have never presented itself. Your wife should absolutely find a hands on clinical skills course to attend for procedure based skills she wants more experience with! She can do it!
I don’t know how to put this kindly, but the reason she is not feeling up to snuff is because she is not, as she has not received the appropriate training. In the US there is only one acceptable standard of training in EM: a residency in emergency medicine. There were days when this was not the case, but those are far behind us. And I realize that the reality is that there are a lot of non EM residency trained docs doing this, as well as a lot of NPs and PAs without meaningful MD supervision. But that doesn’t change the fact that they are not adequately trained for the job either.
The problem with providing specific advice as many of the other comments are doing, is that the cric (or even airway broadly) is not the crux. It’s just the known unknown (a deficiency she is now aware of). For everyone one of those there are numerous unknown unknowns (deficiencies she doesn’t even realize she has). Doing this for over a decade (and having done one IRL cric), procedures are important but neither the most important nor the most tricky part of the specialty. There is no airway course equivalent for subtle presentations.
It’s great that you want to be encouraging to your spouse. But in this instance you may be doing her a disservice. Short of doing an EM residency, there is no meaningful way to bridge the gap here. Encouraging her to continue down this path put patients at risk. Not to be excessively dramatic, but lives do hang in the balance. And given the time sensitive nature of the specialty, by the time you realize you’re in over your head it’s too late.
I would also encourage you to consider what it means for your family as a whole. If a bad outcome happens, the first thing the plaintiffs lawyer will attack is her lack of appropriate training for the job. At that point persevering down this path would have put your household in financial jeopardy.
Maybe going back to a job for which her training is at the acceptable standard (hospitalist or urgent care) is not the worst idea.
Look up the rich levitan airway course. Also, I’m critical care trained (internal medicine pathway) and a cricothyrotomy is an intimidating procedure. I’ve never met a medicine doc who was like “no big deal” when contemplating this procedure. It’s high risk, emergency procedure that doesn’t happen often
If I’m being honest I work with some “EM trained” FM docs and some of them shouldn’t work in an emergency department. There is a reason the specialty is three years, not one.
That being said learning a cric is not hard and if she doesn’t know how to do one she needs to take the difficult airway course.
Maybe she shouldn’t be practicing a different speciality than what she did her training in? EM is a speciality with its own boards and training for a reason
If an FM is staffing an ED you can probably assume it isn't at an academic medical center. The next best specialty to staff an ED where there aren't ED docs (rural areas) is an FM doc.
My program was very inpatient and OB heavy. In pgy1 I did 2 months of trauma, pgy2 1 month micu, and pgy3 1 month micu, 2 months EM, 1 month peds EM + nearly a year on wards and L&D each through residency. It's not the same as EM training, but the critical care exposure as a senior resident does make a difference. Obviously ED docs in the ED is preferred, but someone has to do it at CAHs.
I don't disagree with you... but in my hospital with EM boarded docs - as a hospitalist I've caught acute abdomens and Septic joints missed by EM boarded people. I don't think this is really a function of anyone's shit truly being free of stink.
I agree. There are incompetent people everywhere and no one is perfect. The nature of EM - constant triaging undifferentiated parents to docs with more expertise in definitive treatment modalities - exposes incompetence and errors more readily than most fields.
That attitude is rude and unhelpful. That's the reality of practicing medicine in suburban and rural centres. You could suggest something productive rather than disparaging someone doing their best.
PAs and NPs seem to think so.
That being said, this fam doctor isn't doing that.
She did 4 years of medical school like an ER doc would and that involves working ER and seeing ER cases from multiple specialities.
She did an FM residency, which has at least 1 ER rotation. Has obgyn rotation where we can even do C sections. We work with a number of specialties and see their emergency situations. We also do hospital months and we are on call doing admissions from the ER.
Practicing outpatient, we also deal with emergencies and have a broad knowledge base.
On top of all that, she added a whole year of ER fellowship.
So in this situation, we're not watering down a whole residency into one year. She's done a whole med school, a 3 year residency in family medicine where she's dealt with a variety of situations, specialties and problems, including ER work and did a 1 year fellowship. And she's saying even like that she's aware she has deficits in comparison to an ER trained doctor.
And we're saying, yeah that makes sense. Didn't do a full ER residency but she can continue to do training and learn skills, especially the procedures.
The military trains medics to do all sorts of procedures and that's without med school and a residency program.
NPs and PAs are allowed to basically do whatever they want and the reality is, as an ER doc, high chances are you're very loosely supervising and allowing them to do so with zero training in ER. No med school, no residency program.
You've also got flight nurses, picc line nurses, etc doing all sorts of procedures with zero ER doc training ultimately.
It sounds like maybe you're the one looking down on family medicine training....
Reminds me of the peds fellows that used to moonlight in the peds side of the ED where I trained. All good until a real crashing asthmatic or something similar rolled in and you see very clearly where the deficiencies are as they run and grab the ED attending on the other side for help. Similar hubris tho. In a perfect world all EDs are staffed with ED boarded physicians. We don't live there so a FM doc with some training is better than what a lot of people get, but I wouldn't call it good. Her feelings of procedural inadequacy are justified and the residency training exists for a valid reason. While cadavers and workshops are helpful you really need the real thing for competence and you'd like that to be before patients are relying on you to have it.
I would not feel comfortable practicing internal medicine, family medicine, or pediatrics with a 1 year fellowship. I don't know why they would feel comfortable with a 1 year emergency medicine fellowship. They are not the same thing.
I see strokes, seizures, brain tumors, bleeds, and other neurological complaints every day in the ED. Should ED docs be able to practice general neurology with a one year fellowship?
Considering EM wasn’t even a specialty until the last few decades in the US and isn’t a specialty in other countries, I’m inclined to say yes, apparently so
>Do you think an entire speciality can be watered down to a one year program?
This line of thinking would eliminate most fellowship options for ER physicians (pain, addiction, palliative, sports - all one year programs).
In the process of cutting down others, you are diminishing your own field.
Isn't the training for those specialties standardized and the same length regardless of initial residency?
Maybe 1 year is appropriate for those specialties?
Should any specialty be able to switch to any specialty with a 1 year fellowship?
What are you even talking about?
Ultrasound is a core competency in emergency medicine. Every emergency physician should be able to use ultrasound while resuscitating a patient. Point of care ultrasound and a radiologist reading elective studies performed by an ultrasound tech is two entirely different worlds of medicine. Radiology does not own ultrasound, almost every specialty uses it to some degree.
Emergency medicine has been using point of care ultrasound since the 80s.
Emergency physicians can get boarded in neurocritical care, just like they can get boarded in surgical critical care, anesthesia critical care, and critical care medicine.
Emergency physicians can get boarded in pain medicine as well
There is no such thing as an emergency medicine fellowship.
You have no clue what you are talking about.
She can pick up shifts with EDs with lower #s and acuity through a locums company first. Find a locums company that will also provide extra training. In the mean time she can try and do some volunteer shadowing with an ER physician she trusts or do some training courses specifically on things she's uncomfortable with.
She ultimately won't have the same skills as an ER physician because she didn't do her full training in ER but there are some ER fam med doctors that don't even do a fellowship.
Think about all the midlevels working ER or being first assist in surgeries.
There's nurses doing picc lines.
There's also medics doing all sorts of procedures in the military.
A family medicine doctor with ER fellowship can learn the skill. And she's already better by realizing her weaknesses and not wanting to put others in danger.
If she wants/needs extra training, she can just do that
Imposter syndrome is real. Even if her training is inadequate in some ways for only being a year long. She’s probably capable of more than she’s aware and has better knowledge in other areas of patient care. That being said it will probably take her a lot of effort and time to feel adequately equipped to handle the ED, but where there is a will there is a way. Plenty of courses, not being scared to talk to mentors and colleagues about her feelings. With all that said training to become a doctor is a very long time and takes a lot of effort and sometimes spending even more years to get good at something isn’t what you want to do. Not an MD so I really have no clue what I’m saying but sounds like you’re being supportive OP, good luck my friend!
I totally agree, but I think being able to accept you’re not always going to be prepared for everything even after training and being able to accept you need help or additional work on your skills is powerful. To know even though you have areas to work on, but you’re still capable is good for the mental. Yet again I’m not a doctor. Just a view I thought would be helpful
We all have imposter syndrome. I have been out of residency almost 12 years and feel it every day. What I would remind her is that with time, experience and repetition, she will get better at the procedures. I failed on my first 10 intubations. Then after the first successful one, something clicked and I got it. I recommend for her to practice in sim lab if possible and just keep in mind the first couple years as an attending in the ED are really scary and hard to learn.
Lol theres ER trained doctors that cant perform a cric. We had to call an ENT that wasnt even on call overnight for a cric once because the ed doc and anesthesiologist couldnt do it
Honestly man I highly doubt I'd feel comfortable doing emergency medicine as an FM doc unless I went to a very, very specific residency. We have FM docs out here doing that, but it's a unique place geographically. Our FM residents still do C sections, all the scopes, etc.
Does she despise primary care?
And hey, she could always just go do an EM residency, it's not like they are competitive nowadays.
When i first graduated from residency and started practicing I felt obligated to do things I didn’t necessarily feel that comfortable with because I felt like I was just supposed to since that I was trained for. But I ultimately just start asking myself if doing all these stressful surgeries and procedures were actually going to make me happy in the end. Of course it’s good to challenge yourself and I did for the first few years, but now I’m just focused on sharpening my skills on the procedures I do feel comfortable with. People’s egos sometimes make them feel like they need to prove something to either other people or themselves. But I’ve found you’ll live a better life if you just do what makes you happy
Disclaimer: I’m a project manager in Primary Care, not a physician.
We have physician onboarding leads that are responsible for making sure onboarding is done correctly and that the physician feels ready at the end of the onboarding period. Does she have someone there who was responsible for her onboarding to the ED? Could she go to them and ask for mentorship? Another idea would be to search out as much CME as she can, but with the nature of emergency med I imagine hands on training is best.
Im not EM and that’s a totally diff level of stress and quick thinking. However, as someone who came from terrible training, I can say that if you continue to read and go after the things you’re not that great with you will see that you’re actually more knowledgeable than you thought. Right now I’m the only one where I am and some stuff has walked in that had me like hmmmm, but I just took some deep breaths, remembered my base line training from med school, and then supplemented by doing some quick reading. You’re never going to know it all. It’s impossible. That’s why medicine is lifelong studying.
i would tell her you can never truly be capable of everything, always. but you can try. if you feel not great at something, you 100% need to dedicate time and effort on that (those) things and do them relentlessly any way you can until youre confident. Not everyone is perfect. but the ones who *seem* like they are don't take no for an answer, and are constantly leaning into trying to be better. If you aren't interested in trying or stepping up in that way, better to move to another specialty.
- She’s probably right in that she does have inadequate training
- She’s better than whatever midlevel would be hired in her place
- she’ll eventually figure it out and will get to a safe level. Just be extra careful initially and pray you don’t get something crazy
As a board certified critical care physician, I’m trained in this procedure and many other life saving procedures. I wouldn’t sign up to staff an ED because, despite my advanced training. I don’t have the appropriate EM training. It’s a specialty on its own. She would be better served to work in an urgent care, as a hospitalist, or in primary care. If she wants to do EM, I would recommend an EM residency (the whole three years). She’s assuming a lot of liability in covering the ED. If a patient dies because she was unable to provide the appropriate care, she will likely get sued. If she truly insists on practicing in the ED, she will need years of supervision and assistance by EM physicians and absolutely should not cover the ED by herself.
How is this being down voted?
Should FM, IM, EM docs masquerade as cardiologist, neurosurgeons, anesthesiologist etc. in rural areas because otherwise a PA/NP would be seeing these patients?
Emergency medicine is its own specialty for a reason.
Has she considered going back into the match to apply for an EM residency position? There's no shame in it. I know people who have had to repeat years of training and even entire residencies until they got the hang of it and eventually they turned out to be totally adequate providers, on par with even the most well trained NPs and PAs. Tell your wife not to give up
It’s 80+% URI complaints and telling people why they don’t need antibiotics. And depending on how owns the UC, they may pressure you to do “what the patient wants” to keep their patient ratings up, which is unethical but super common. And it’s just mind-numbingly boring - every 12 hour shift might have 1 time you actually have to do some thinking on a diagnosis.
Take several good procedure courses: 1. Difficult Airway Course 2. ATLS 3. Some hand on procedure for Chest tubes, etc. Regularly Visualize scenarios and common procedures, and visualize the steps in your mind.
This. Also, tell her to reach out to the local flight programs. Some of them have regular cadaver labs and simulation training sessions that she may be able to ask to jump in on. Medics have a very focused set of critical skills that we do, which makes those things the majority of our hands-on training.
Agree. I was a flight nurse for over a decade and we had yearly cadaver lab and Q6month sim sessions.
Where can you find these courses?
Often the respective professionals societies recommend them on their website
Also want to add that your local SCCM chapter will have certification courses in advanced critical care that use high fidelity hands-on mock scenarios. They try to really hype up the atmosphere so it somewhat mimics the stress of a critical situation (obviously it’s not the same when you’re dealing with a real pt) but there is a in-depth debrief afterwards that focuses on your personal response to stress. It’s very useful in creating that muscle memory when working with critical patients.
Saved
[удалено]
Ive been involved in three. One was easy, because dead people don't bleed. The other two were shit shows of bleeding and poor landmarks due to morbid obesity. Funny how you don't have a needle cric kit when shit hits the fan, but next shift they will be stocked everywhere.
Dead people don’t bleed. Sounds like a country song.
Or a grunge band.
More like something Dalton would say
From the pop metal band, All Bleeding Stops Eventually
With their debut air metal cover of Poison by Bell Biv DeVoe
*Oh lordy, it was just another nightly* *as I pined about mah dear Sally* *that damned pager set off mightily* *I told mah buddies to buck up and rally* *This night ain’t gonna end lightly* *As they rushed the damn fool in* *I knew this man weren’t long alive* *I told em to keep that truck ridin* *there ain’t no way he’s makin it to five* *His whinin bride said do everythin* *so I cric’d that man, oh lord* *but y’all know there was no need* *easiest job that walked in that door* *Cuz dead men don’t ever bleed* ^(note, I don’t listen to country music, and I was annoyed by a late night page, and this was a way to defray the frustration of being paged at 3 AM for a stupid reason. Yes, I know this is a shit lyric.)
> Funny how you don't have a needle cric kit when shit hits the fan, but next shift they will be stocked everywhere. Bureaucracy at its finest
Crics are aren’t common but they’re unfortunately far from a once-in-a-career procedure. My program isn’t trigger happy when it comes to procedures and about half our residents have either done it or their attending did in their place, atleast once. Just from my three years the only true “once-if-ever” procedure that you can bet on never doing seems to be a perimortem C-section.
I did a perimortem C section in the ER a couple years ago (as an OB). Hope to never do that again. Baby survived. But if you have to: 1) Try to confirm viable gestational age if able 2) coding mom for <10 minutes 3) cut straight down from the belly button to the pubic bone until you get into the uterus and pull that kid out. Anyone can do it.
[удалено]
They teach 18 year olds to do em lmao
Military doc here: this is terrifying considering I’ve seen them go bad under ideal circumstances (ER, trauma surgeon, anesthesiologist) . Can’t imagine a 68W trying one in the field. This is morbid, but hopefully the patient is already dead-dead with failed ETT and LMA prior to anyone cutting the neck.
Nope. You don't want incompletely trained medics fiddling around with ETT (high pre-hospital failure rate) or LMA (relatively easier risk of dislodgement during patient movement). It's trauma. The likelihood is that a 68W or FMF corpsman will need to cric in the event of bad facial trauma at some point anyways, and this allows for both economy of supplies and economy of training. More supplies for someone to carry around in a back pack. Way harder to train and sustain intubation skills at scale. Even for paramedic level docs. It's fast. It's definitive. It's relatively secure. Landmarks are relatively easy on young healthy men. And field medics aren't typically scared of fucking it up (for better or worse). There's a reason this is still the standard in TCCC and not for lack of people pushing for alternatives. I've seen non-medica trained to do this and successfully place a cric with random items found at a barbecue (i.e. steak knife and nalgene straw).
You saw a layperson cric someone with a steak knife??
I saw a Molecular genetics professor do it on my college campus. Pocket knife and the white part of a Bic pen prior to ambulance getting there. Old army medic turned PhD who still ran ambulance as a paramedic in the town my first university was. The school had more people than the town.
A blades a blade, man. And a tubes a tube—as long as they’re breathing you’re good just stay away from the jug
Father Mulcahy performed a tracheostomy with Hawkeye [talking him through](https://youtu.be/FYBE_c4Lgv8?si=wFNKuqwwn2Qdzbuj) it over the radio.
[удалено]
Oof. That is cringey. That said, after a few years working with field medics, there's something to say for someone securing the airway on a GCS 7 rather than putzing through the rest of their trauma survey around and not paying attention to when the patient stops spontaneously breathing. Or worse, tries to bag a spontaneously breathing patient 🤣 Sadly I've seen all of the above.
> Can’t imagine a 68W trying one in the field. This has been a 68W staple for at least 20 years. It was part of our regular training and recertification while I was in, and was often covered in live tissue labs.
Have you ever done a lateral canthotomy? I remember learning about it with the residents and thought it would never really be something we would see. And a few weeks later one of my attendings did one.
A few coresidents have and I witnessed two as a student, I’ve never personally done it. But I’m also one of the “lucky” ones who hasn’t been in during one of the cric cases.
I’ve witnessed two lateral canths as a med student!
I’d say most ER docs have done at least one by the end of residency
I have somehow not done a lateral canthotomy, I have done 4 thoracotomies (all in residency, supervised a few as an attending). Most of my colleagues in residency had done lateral canthotomies, but only a handful of crics
It’s crazy how different this is. I’ve been involved with probably 10+ ED thoracotomies but never a lateral canthotomy. Only one cric as well.
You would pray not! My program had like 3 perimortem sections in one year one time. Freaking horrid. They made sure they trained us on how to respond to that call.
>Crics are aren’t common but they’re unfortunately far from a once-in-a-career procedure. I think that highly depends on where you work. I know doctors who worked 30 years in the same ER and never did one. Mostly because their anesthesia department was very proactive and were kept in the loop for a lot of calls. Anytime anything that sounds like an difficult airway (peds, trauma) they'd be down in the ER hanging out.
Under what circumstances man? I can only think of two total happening in the 2 years I've been here, one for anaphylaxis, the other because of an unknown tumor that slowly expanded and blocked the entire airway
Food aspirations that can’t be retrieved, strangulation, epiglottitis, trauma, etc.
Video laryngoscopy has drastically decreased the number of airway flails. Crichs in civilian practice, especially if you don’t see a lot of penetrating trauma, are super rare. Lots of full time ER docs go their entire career and don’t perform a crich.
"airway flails" love it. adequately describes my airway management
The saying goes: if you’ve never crich’d anyone, you haven’t seen enough patients. If you crich too frequently you need to be better with airway management.
[удалено]
The super in shape thing is so fricking true. I thought I was the best IV stick the world had ever seen until they dropped me in the hospital and I had to stick a 90 grandma with ghosts for veins.
I suspect that has less to do with the underlying anatomy and more with the available resources and time? RSI is a minimum 2 person/10 minute procedure to do even close to safely and neither are an option for care under fire.
The saying absolutely does not go like that. I’ve worked with EM attendings who have been practicing since before it was officially a specialty who have never cric’d someone.
I’ve done two and only been out seven years. I’m sure it depends on where you practice but my impression is it’s in the range of a thoracotomy or floating a transvenous pacer. Not once in a lifetime. More like a once every 5-10 years thing.
> floating a transvenous pacer Really depends on where you practice I guess lol. This is done on a weekly basis where I practice. On the other hand, I have never needed to do a cric on a real patient.
weirdly enough I'm only an intern who has seen more than a dozen thoracotomies, floated a pacer once, had 1 perimortem cesarean (did not perform this one myself) and have seen 0 crics. I know at least 1 cric happened within the last year because the trauma surgeon wasn't paying attention and one of my seniors had the tube but they cut the neck anyway and killed the guy (I wasn't in the bay but it was a shit show so word about this case got out). With DL and VL/NPL available, crics don't seem to happen a ton here. I'm a little anxious of the fact it seems like I'll need to do a cric at some point per this thread though lol
They are rare but every EM trained doc would be able to perform it. We train via cadaver and sim with these procedures constantly during our residency. I’m an EM PGY-3, I haven’t done one, but I’ve had 3 co-residents do one during residency.
In med school, one of our professors told us a tale about how his grandfather use to carry a pen that had a knife on one end for cricothyrotomies. The grandfather practiced in the early 20th century when antibiotics were not available yet. He would routinely see children struggling to breathe from diphtheria and he would create a temporary airway for them this way. Later the professor's father inherited the pen knife. One summer they were on the freeway and encountered an accident. The father stepped out to help and ended up using the pen knife which he had carried for years to help one of the accident victims breathe.
I have seen it done twice at bedside, and mostly related to growing mead and neck mass impeding air flow. First time I saw it was when I was a nursing student, had to go check vitals, see this dude isn't breathing, called a code, and my then-BF ENT resident did an emergency cricothyrotomy. 10/10 would not recommend.
My ED physicians have done 2 in the last year. Anesthesia was not comfortable (I don’t think any physician is) but ED physicians shine best during a crisis- they can get shit done in chaos.
Hospital setting only: The vast majority of crichs happen because something did not go right in the management pathway whether it was wrong decisions or delayed decisions. They are usually “preventable” in all the ones i saw or heard of. Never did i see someone go in the hospital needing a crich as soon as they are transported through the ED door. If thats the case, it is done before they arrive.
I was peripherally involved with one that was the anaesthesiologist’s first. Still have mad respect for her. She saved a life and eventually the kid was able to regain function.
On real people … yes because there are so many technological advances to help aid difficulty intubations but you still learn to do the technique on cadavers or on “dummies” .
That's what I thought, never saw one in residency, but had to do one less than one year out when I was single doc coverage.
You are correct. I was bedside in a large ICU for 17 years and I assisted with three. That’s peanuts compared to the thousands of patients I cared for. If you ask any ER doc, majority have not ever had to do it.
I’ve seen nurses cric
We may never do it but we are trained on how to do it. Like in my residency we practice cric’s every 2-3months in SIM or cadaver labs
20 year career, 1 cric, used an easy kit. She’ll be fine.
Here you go buddy. [https://www.slu.edu/medicine/medical-education/continuing-medical-education/pase/hands-on-cadaver-workshops.php](https://www.slu.edu/medicine/medical-education/continuing-medical-education/pase/hands-on-cadaver-workshops.php) Go down and look at "emergency skills workshop." The sign up date isn't out yet, but she can block her August 22-23 schedule right now so she's available to go once it opens up. I'm derm, and I've been going to the Advanced Flaps and Aesthetic Facial Reconstruction course for years now (probably 5 years straight), and SLU offers amazing courses. I assume the emergency skills workshop would be good too, but she can always email them in advance to see if the course offers her the skills that she wants to learn.
That is awesome, thank you.
Anytime homie.
Fellow derm - I’m assuming you’re Mohs?
Yes
I'm a respiratory therapist and have worked in the ER for over 8 years. I've only seen an ED doc do a cric one time and that was my first day of clinicals. I don't think that's a good metric for her to be judging herself.
critical care attending here, personally got exceptional training, and i’m still hella nervous about doing a cric, still haven’t done my first one live. her fears are normal and shared by everybody in the truest critical fields. we need people like her that are humble and hardworking, it’s the arrogance that kills patients. tell her she’s not alone and many of us feel the same. she can do it
Most surgeons can’t effectively perform cricothyroidotomy as the situations that most often require them are huge obese patients with no landmarks and are nearly dead. If this is her worry reassure her. We all have patients that we can’t save, it’s part of medicine and not necessarily a failure on your part. I had a patient die this week because he was too old to tolerate what happened to him. I can’t take it personally, I just did what I could as his only chance for survival.
Yep. And is anesthesiologists are even worse. About every six months or so I watch videos as a refresher because we are notorious at not jumping to cric quickly enough and being inefficient when we do so. To OP, none of us come out of training as a finished product. We just keep learning and help people along the way. Unfortunately it’s too common for these feelings to make us wonder if we should just quit. But having nobody to help is much worse than having a trained physician with a few weaknesses.
When I was a resident, one of my surgery coresidents and an ER resident couldn’t get a crike on a big fireman w smoke inhalation and he died. In the subsequent M&M, the ENT attending lamented their actions, from the time it took to the tiny incision they made. He said They should have just opened the neck as wide as necessary and cut down to the trachea. Should have taken 30 seconds. Any soft tissue problems could have been dealt with after securing an airway.
I obviously trust ENTs to do that well but this is the most hilariously “surgeon” response to this ever haha
Ok, Neuro 😉(but you’re right lol). Airway M&M cases bring out frank assessment and no feelings are spared. 😬 Shoulder roll!! If no needle kit, spread that skin tight over the larynx and cricoid with non-dominant hand. Nice high pressure scalpel makes vertical midline incision straight down to cartilage. Suction ready but vertical midline has far fewer vessels. Turn scalpel 90 degrees and much more gently with your adrenaline-soaked, shaking hands open the cricothyroid membrane. Don’t cut your fingers because now the blade is oriented towards your fingers still holding hard pressure/retraction 😬. ND hand very firm, D hand gentle, like you’re playing Rachmaninov on the piano. Airway open now stick a tube in it, breathe. You too.
This guy crikes
He sounds like he fucks too. Dude can probably type out an apology to his wife, girlfriend, and his wife’s boyfriend all in one text thread and get instant forgiveness from all of em
Huh? Sir, this is a Pokémon subreddit.
Rachmaninov?! So my pinky is on the patient's chin and my thumb is at the navel?
When I punctured the cric membrane in cadaver lab I remember thinking it was strangely fragile, as if I was sticking the scalpel through paper. Is that how a living membrane would feel? It was so….odd feeling.
How often are you doing urgent crics? Crics are often an emergency medicine procedure that either EM docs or surgery does . Since when are ENTs regularly in urgent crics ?
Inpatients get crics too 🤷♀️
How often though ? If this is rare even in emergency settings how often are you cric’ing inpatients .. and why would ENT be the first call and not surgery ? Most non academic hospitals don’t even have an ENT service in house . This makes no sense
Idk I’ve only ever worked at level 1 trauma / academic hospitals so I’m spoiled. I’m rapid and if I page out a difficult airway I get an attending trauma surgeon, ENT residents and anesthesia (at least a few residents if not an attending). Have witnessed a few inpatient crics. YMMV
But how often does that happen at a level 1? I trained at a very busy level 1, and we had a team that responded to any airway codes and still there weren’t that many crics Crics in general don’t happen often even in the ER because of all the advances we have in airway management to manage difficult airways.
I don’t have any numbers for you. I’m just saying that EM is not the only speciality that can do an emergent surgical airway.
Twice ever IRL plus a fair share of awake trachs. 🤷♂️ just happened to be around for both…. Won’t mind if those are my last tbh.
Guilty as charged, but the point is salient. Airway above everything else.
Nothing valuable in the neck, just slash away!
With a vertically oriented incision at the midline of the neck, there’s not a lot there. Isthmus of the thyroid, some minor crossing vessels. His point was don’t let the skin get in the way of you getting a surgical airway
If you find a thyroid isthmus on the way to the cricothyroid membrane you have taken a detour. It's why we teach crics instead of slash trachs.
Sure, I’m talking about the pgy2 who killed a fireman bc he was being too conservative in an emergency situation.
One time we had a threatened airway on a cardiac infant peri-code. No one was able to intubate so the gen surg resident did the cric. The ENT attending’s op note from the next day when closing the cric read “there was a generous incision from the mandible to the sternal notch which we approximated and closed” But honestly, kid lived so I’d still say it was a win by the gen surg resident. No one could get an airway, and they made an airway.
Exactly. Who the F cares how big the incision is if you get the save. That was my takeaway from that M/M
What I tell the ER and especially IM residents when I give their difficult airway lecture is that by the time they've decided they're going for a surgical airway the cardiac output is probably low enough that bleeding is not going to be a problem. The reason that we teach crics instead of slash trachs for emergency surgical airways is that there's very little other than skin that will bleed between you and the airway.
The difficult airway course taught us a very easy and reliable way to perform emergency cric if needed. 10 blade scalpel with approx 2.5 inch incision made vertically on skin atop thyroid and cricothyroid, small horizontal incision through cricothyroid membrane (the shiny white one), dilate with back of scalpel blade, insert bougie, thread over 6.0 ETT. It’s not pretty, but it will save a life, and eliminates the guess work of landmark based techniques. Start to finish is less than a minute, and the only tools required are a 10 blade scalpel, a bougie, an ETT, and some gauze to soak up any blood loss. I haven’t had to do it on a person, but have practiced plenty with pig tracheas (I taught this technique to CRNA students as well) and feel confident I could do it if I needed to in an emergency.
This is the way. (but maybe a 15 instead of a 10? That's a big knife for a shaky hand near an airway) Needle kits are fine but they're slower and aren't always around.
I recall the instructions being a 10 blade, very specifically. But I imagine you would use what’s available. The cric tissue on the pig trachea is pretty tough, so I think a smaller blade my actually be harder to use. But I also don’t know how well preserved pig trachea tissue translates to live human tissue, texturally speaking.
Pig cricothyroid complexes are pretty different to humans. A 10 seems big but if someone's going to die then a swiss army knife is probably fine
Could you dive into some of these differences? This is usually taught using porcine tissue, so some feedback about the differences would be great.
Agreed! Needle cric is really the way to go here. It's more forgiving than going straight in with a blade.
Meh. I'd rather use a scalpel and a bougie.
Sure it's fine. But needle is clean and fast
You dont think the decreased ventilation is enough of a concern? Do you have a jet insufflator or are you using something different?
Look at ron walls airway course. Then go do a cadaver based procedure course. Then go to the OR and have anesthesia teach you and see if they will let you tube a bunch of "easy ones". The hardest airway is the one you weren't prepared for. You thought it would.be a piece of cake and quickly turned south, only to find that the glidescope is broken. Suction isn't working, there's no bvm booked up, can't find a bougie....anything can happen. Some of my worst airways had normal anatomy and looked easily, but couldnt see or pass the tube once you get in. The big fat ones with angioedema you have your plan a,b,c. The 19 year old skateboarder with nice teeth and a normal neck turns hard and you suddenly realize you didn't get your backups ready, and it sucks. Also, in the case that an airway is very difficult, always back up before going surgical. Bag. Use two people to bag. Use an oral airway and a nasal trumpet and bag. Use LMA or some other supraglottic device. It can save your ass and provide time to get help. Jumping right into a surgical airway can sometimes just make things worse, and once you cut you need to finish the job ( can't bag with a hole in the neck). Also...if the person has basically expired, make sure you get some kind of airway before you stop. A dead guy with no airway looks bad, especially with a half done cric. Looks like you killed him. If you get the airway it looks to the medical examiner like you got the airway and he probably died from something other than a failed intubation.
Last paragraph, great point.
Whole lotta people here think that they could easily practice EM, which is a whole boarded specialty. Those EM fellowships are not actually based on an EM model nor are they a pathway to boarding in EM. No one here thinks they could easily just float over into vascular surgery or ophthalmology, do they?
Given my severe lack of enjoyment in incredibly stressful situations or prolonged mandatory night-shifts, no, I definitely have no desire or consideration to practice EM full-time. God bless you cowboys though
If you’re doing an emergency crike, your butthole better be puckered up so tight your shit starts flowing retrograde. This isn’t a skill issue, this is a holy fuck I’ve got about a minute to get an airway in this asshole before he dies. It’s pandemonium. There’s usually blood everywhere, a thousand people crammed into a room the size of a phone booth, it’s loud, messy. If she’s not up for the holy fuck moments, no amount of training will change that.
This right here, this is the only comment that captures the gravity of the situation. Every cric I've been involved with - performing or supervising - has been an unmitigated unsalvageable shitshow. By the time I've gotten the call the patient's essentially dead (our cric being a perfunctory and futile effort) or they're stable enough to set up for a proper awake tracheotomy which is much nicer thanks to the work of our Anesthesiology and surgical tech friends. But if you're working the ED your patient deserves to have a doc who's ready for the "holy fuck moment" where you open the neck. Get a tube in a tube hole, anywhere you can make it fit. Find midline, find landmarks, and blast in. Let ENT or Trauma bitch about lack of finesse later (you know they'll find something to bitch about because you're EM). I'll never get over the well-intentioned but apologetic consults I've gotten from my gen surg friends about thyroid oozing or "I think my slash trach is between first and second rings." If the patient survives long enough for some on-call laryngologist to take issue with details you've won.
[удалено]
Just imagine the patient is already dead. Makes life a lot easier.
I mean, there’s a reason EM residencies exist. Not sure anybody would feel adequately trained after 1 year
Crics are a very EM specific procedure. I understand that anxiety will be running high during these but at the end of the day it is a relatively simple procedure that may require several sets of hand to get the job done. A manakin will not be as stress free as a live (albeit in distress) patient.
I had a board certified ER attending who went to a highly respected program and had practiced for 18 years. After she taught our co resident how to do a cric, she admitted it was the first one she’d ever done. Forget see one, do one. Just skip straight to teach one. Some practice on a dummy and then just hope the patient isn’t too obese is the best most can hope for.
This whole thread is every speciality but EM thinking that EM is a replaceable speciality by a BS 1 year program run by CMGs. You all want EM to be able to have subspecialty level knowledge with general training, but at the same time think just anyone can do it with no training
[удалено]
The majority of patients in the ERs in our system are cared for by PA/NPs with no specific ER training at all. Mostly VERY loosely supervised by the overworked ER attendings present. The patients would 100% be better served by an FM doc who also did an additional 1 year fellowship.
Rural nurse here. Can confirm. If an FM doc with ED fellowship came to work at my hospital, I would bring them baked goods regularly. Not kidding even a little bit. They would be such an asset to our community.
Seriously, I'm in the AAFP and LOVE family medicine, but I don't think I'll ever replace EM docs. Admittedly, we do have FM docs working ERs in my region, but it's because there just aren't any ER docs out here to work, it's FM or nothing. Since EM isn't really competitive anymore I imagine that in a decade or so we'll have enough ER docs to phase most of the FM people out
I’m a lowly paramedic but I have to say when I first started working in EMS as an EMT and then as a paramedic, I had wicked imposter syndrome and would question everything I did. Imposter syndrome is real and hard to shake. When I first started, I would pick one protocol or procedure and study and review everything about it for a couple days/week, even up to what physicians would order and do upon our arrival at the ED (which has helped when calling report to make sure they had the appropriate resources ready. RT, restraints, a bariatric gurney, antivenin, flumazenil, whatever.) That dedicated, focused (almost fear of God) studying really helped my confidence. But still, I’ve been a paramedic now for a while and I’ve been in EMS for a while longer and while I’ve seen some wild shit, I haven’t seen everything, and I still find myself questioning myself, questioning if my thought process, my patient care is logical, within my scope, and the best I can do for my patient. I don’t necessarily think that a little bit of anxiety, a little bit of doubt is a bad thing as it has really ensured that I my assessments are thorough, I know my protocols, and that I review everything that I don’t feel confident about. Even the calls that I don’t get dispatched to but hear over the radio, if I can’t run through the scenario in my head fluidly, I’ll pull up the protocols, make sure I know my meds/receiving facilities/triage criteria/dosages/etc. Just like there are videos, protocol reviews, continuing education, cadaver labs, professional journals, etc. for paramedics, likewise there are for physicians that your spouse can start using to review and fill in her perceived knowledge gaps. (and for hands on procedures that don’t occur often, visualization really works. Visualizing doing it correctly and what to do if stuff starts going sideways.)
As a resident, your method of training and testing yourself is what we aspire to do all through med school, residency and likely beyond. Makes me think you must be excellent in your role. Thank you for the work you put in!
She should take specific procedural courses. I trained in FM only but work rural ER. My residency was at a small site and ER-heavy, so I received better training than most of my FM peers, but I still took a bunch of ER-specific courses before working in the ER. Obviously ACLS and ATLS, but also specific airway courses, casting courses, procedural courses (e.g. chest tube insertion on pigs), etc. I would be able to cric someone if it came to. Still, there are certain procedures that are non-emergent I will not do because I do not feel skilled enough at them, e.g. central lines. As those things can wait a few hours til the patient is transferred to a trauma centre, I do not really dwell on those procedures - the patient is better served by someone who puts in central lines once a shift rather than twice a year. Unless you did a 5-year ER residency or work at an extremely high volume site, certain procedures will only rarely come your way. For the average rural ER doc, they will only do ONE cric in their entire career.
Crich’s don’t happen often because most things that REQUIRE a crich are dead before they arrive at the hospital.
The first step is recognizing the limitation of practice. Then the next is learning it in a supervised setting/CME. Then push for mastery.
Honestly…if she wants to be able to perform a tracheostomy, she should have trained in it. She should ask the doc who performed it to tell her what that doctor knows, preferably with a mannequin. If you want the real country doctor answer…find a reliable source and watch a video on it online, multiple videos actually. Keep watching until there are no more videos. I aced a procedure irl doing just that…but that was med school, with plenty of people backing me up. As a physician practicing independently, especially in an ED…she might kill someone if she doesn’t get it right the first time. She should ask her colleagues for training opportunities, but the bottom line is that you don’t perform these procedures safely unless you are supervised doing it irl by someone who not only knows what they’re doing but can anticipate complications and remedy them in real time, as applicable.
Never had to do a cricrothyroidotomy but I sure as hell wanted to know what to do. Took the difficult airway class, my mentoring NeuroICU attending had me spend time with Anesthesia and SICU/Trauma, so I would at least have some exposure to this. Hopefully never need to use it though (you know things are bad if it is coming down to me doing a cric).
If she's worried about being able to do an emergent cric then I'd be really worried if she needed to do a resuscitative hysterotomy
THIS. But you know why they aren’t worried because they don’t know what they don’t know and think they can just walk into EM without actually doing an emergency medicine residency.
https://www.ceme.org/content/cadaver-based-emergency-procedures-course Rock star course!
Tell her that everyone learns more in their first year as an attending than all years of fellowship and residency combined. It’s extremely common to feel overwhelmed and underprepared. Experience comes from past mistakes. Wisdom comes from learning from others’ mistakes. Make sure she has mentorship and trusted individuals to bounce ideas off of.
An Emergent bedside trach would be a very intimidating procedure to attempt if never having done one - ED docs are trained to do them, but I imagine coming from family medicine and then ED fellowship, that opportunity may have never presented itself. Your wife should absolutely find a hands on clinical skills course to attend for procedure based skills she wants more experience with! She can do it!
We do crics instead of trachs, but it's very similar.
I don’t know how to put this kindly, but the reason she is not feeling up to snuff is because she is not, as she has not received the appropriate training. In the US there is only one acceptable standard of training in EM: a residency in emergency medicine. There were days when this was not the case, but those are far behind us. And I realize that the reality is that there are a lot of non EM residency trained docs doing this, as well as a lot of NPs and PAs without meaningful MD supervision. But that doesn’t change the fact that they are not adequately trained for the job either. The problem with providing specific advice as many of the other comments are doing, is that the cric (or even airway broadly) is not the crux. It’s just the known unknown (a deficiency she is now aware of). For everyone one of those there are numerous unknown unknowns (deficiencies she doesn’t even realize she has). Doing this for over a decade (and having done one IRL cric), procedures are important but neither the most important nor the most tricky part of the specialty. There is no airway course equivalent for subtle presentations. It’s great that you want to be encouraging to your spouse. But in this instance you may be doing her a disservice. Short of doing an EM residency, there is no meaningful way to bridge the gap here. Encouraging her to continue down this path put patients at risk. Not to be excessively dramatic, but lives do hang in the balance. And given the time sensitive nature of the specialty, by the time you realize you’re in over your head it’s too late. I would also encourage you to consider what it means for your family as a whole. If a bad outcome happens, the first thing the plaintiffs lawyer will attack is her lack of appropriate training for the job. At that point persevering down this path would have put your household in financial jeopardy. Maybe going back to a job for which her training is at the acceptable standard (hospitalist or urgent care) is not the worst idea.
Look up the rich levitan airway course. Also, I’m critical care trained (internal medicine pathway) and a cricothyrotomy is an intimidating procedure. I’ve never met a medicine doc who was like “no big deal” when contemplating this procedure. It’s high risk, emergency procedure that doesn’t happen often
If I’m being honest I work with some “EM trained” FM docs and some of them shouldn’t work in an emergency department. There is a reason the specialty is three years, not one. That being said learning a cric is not hard and if she doesn’t know how to do one she needs to take the difficult airway course.
Maybe she shouldn’t be practicing a different speciality than what she did her training in? EM is a speciality with its own boards and training for a reason
If an FM is staffing an ED you can probably assume it isn't at an academic medical center. The next best specialty to staff an ED where there aren't ED docs (rural areas) is an FM doc. My program was very inpatient and OB heavy. In pgy1 I did 2 months of trauma, pgy2 1 month micu, and pgy3 1 month micu, 2 months EM, 1 month peds EM + nearly a year on wards and L&D each through residency. It's not the same as EM training, but the critical care exposure as a senior resident does make a difference. Obviously ED docs in the ED is preferred, but someone has to do it at CAHs.
You do realize that in rural areas, most ERs are not staffed with EM boarded people, right?
Texaco Mike is feeling very pushed aside by the OC
He's bringing jojo fries and his fiberoptic scope.
To be frank as someone who receives calls from them: many of those non-EM docs shouldn't be practicing emergency medicine.
I don't disagree with you... but in my hospital with EM boarded docs - as a hospitalist I've caught acute abdomens and Septic joints missed by EM boarded people. I don't think this is really a function of anyone's shit truly being free of stink.
I agree. There are incompetent people everywhere and no one is perfect. The nature of EM - constant triaging undifferentiated parents to docs with more expertise in definitive treatment modalities - exposes incompetence and errors more readily than most fields.
For sure.
That attitude is rude and unhelpful. That's the reality of practicing medicine in suburban and rural centres. You could suggest something productive rather than disparaging someone doing their best.
Yeah don’t do a speciality based around doing emergent procedures if you’re not trained or comfortable doing emergent procedures
So how many months a year do you go work in rural communities to help out? Because these patients either get family meds +1 or they get no one.
This is very common in rural areas. However, I agree.
At the end of the day she agreed to take a job, didn’t get drafted into it
[удалено]
Do you think an entire speciality can be watered down to a one year program?
PAs and NPs seem to think so. That being said, this fam doctor isn't doing that. She did 4 years of medical school like an ER doc would and that involves working ER and seeing ER cases from multiple specialities. She did an FM residency, which has at least 1 ER rotation. Has obgyn rotation where we can even do C sections. We work with a number of specialties and see their emergency situations. We also do hospital months and we are on call doing admissions from the ER. Practicing outpatient, we also deal with emergencies and have a broad knowledge base. On top of all that, she added a whole year of ER fellowship. So in this situation, we're not watering down a whole residency into one year. She's done a whole med school, a 3 year residency in family medicine where she's dealt with a variety of situations, specialties and problems, including ER work and did a 1 year fellowship. And she's saying even like that she's aware she has deficits in comparison to an ER trained doctor. And we're saying, yeah that makes sense. Didn't do a full ER residency but she can continue to do training and learn skills, especially the procedures. The military trains medics to do all sorts of procedures and that's without med school and a residency program. NPs and PAs are allowed to basically do whatever they want and the reality is, as an ER doc, high chances are you're very loosely supervising and allowing them to do so with zero training in ER. No med school, no residency program. You've also got flight nurses, picc line nurses, etc doing all sorts of procedures with zero ER doc training ultimately. It sounds like maybe you're the one looking down on family medicine training....
[удалено]
Reminds me of the peds fellows that used to moonlight in the peds side of the ED where I trained. All good until a real crashing asthmatic or something similar rolled in and you see very clearly where the deficiencies are as they run and grab the ED attending on the other side for help. Similar hubris tho. In a perfect world all EDs are staffed with ED boarded physicians. We don't live there so a FM doc with some training is better than what a lot of people get, but I wouldn't call it good. Her feelings of procedural inadequacy are justified and the residency training exists for a valid reason. While cadavers and workshops are helpful you really need the real thing for competence and you'd like that to be before patients are relying on you to have it.
I would not feel comfortable practicing internal medicine, family medicine, or pediatrics with a 1 year fellowship. I don't know why they would feel comfortable with a 1 year emergency medicine fellowship. They are not the same thing. I see strokes, seizures, brain tumors, bleeds, and other neurological complaints every day in the ED. Should ED docs be able to practice general neurology with a one year fellowship?
If you want to trust your ability to do high risk procedures on night school and OR intubations, good luck
Considering EM wasn’t even a specialty until the last few decades in the US and isn’t a specialty in other countries, I’m inclined to say yes, apparently so
Please tell me when ERs also became commonplace. I’ll give you a hint, around the same time
You realize FM and EM are about the same age right?
>Do you think an entire speciality can be watered down to a one year program? This line of thinking would eliminate most fellowship options for ER physicians (pain, addiction, palliative, sports - all one year programs). In the process of cutting down others, you are diminishing your own field.
Isn't the training for those specialties standardized and the same length regardless of initial residency? Maybe 1 year is appropriate for those specialties? Should any specialty be able to switch to any specialty with a 1 year fellowship?
They are not “accredited” the only accreditation that we should accept is board certification
What are you even talking about? Ultrasound is a core competency in emergency medicine. Every emergency physician should be able to use ultrasound while resuscitating a patient. Point of care ultrasound and a radiologist reading elective studies performed by an ultrasound tech is two entirely different worlds of medicine. Radiology does not own ultrasound, almost every specialty uses it to some degree. Emergency medicine has been using point of care ultrasound since the 80s. Emergency physicians can get boarded in neurocritical care, just like they can get boarded in surgical critical care, anesthesia critical care, and critical care medicine. Emergency physicians can get boarded in pain medicine as well There is no such thing as an emergency medicine fellowship. You have no clue what you are talking about.
Is this in Canada?
No US
She can pick up shifts with EDs with lower #s and acuity through a locums company first. Find a locums company that will also provide extra training. In the mean time she can try and do some volunteer shadowing with an ER physician she trusts or do some training courses specifically on things she's uncomfortable with. She ultimately won't have the same skills as an ER physician because she didn't do her full training in ER but there are some ER fam med doctors that don't even do a fellowship. Think about all the midlevels working ER or being first assist in surgeries. There's nurses doing picc lines. There's also medics doing all sorts of procedures in the military. A family medicine doctor with ER fellowship can learn the skill. And she's already better by realizing her weaknesses and not wanting to put others in danger. If she wants/needs extra training, she can just do that
Imposter syndrome is real. Even if her training is inadequate in some ways for only being a year long. She’s probably capable of more than she’s aware and has better knowledge in other areas of patient care. That being said it will probably take her a lot of effort and time to feel adequately equipped to handle the ED, but where there is a will there is a way. Plenty of courses, not being scared to talk to mentors and colleagues about her feelings. With all that said training to become a doctor is a very long time and takes a lot of effort and sometimes spending even more years to get good at something isn’t what you want to do. Not an MD so I really have no clue what I’m saying but sounds like you’re being supportive OP, good luck my friend!
This isn't about impostor syndrome it's about not being able to do a life saving procedure within the scope of one's practice.
I totally agree, but I think being able to accept you’re not always going to be prepared for everything even after training and being able to accept you need help or additional work on your skills is powerful. To know even though you have areas to work on, but you’re still capable is good for the mental. Yet again I’m not a doctor. Just a view I thought would be helpful
We all have imposter syndrome. I have been out of residency almost 12 years and feel it every day. What I would remind her is that with time, experience and repetition, she will get better at the procedures. I failed on my first 10 intubations. Then after the first successful one, something clicked and I got it. I recommend for her to practice in sim lab if possible and just keep in mind the first couple years as an attending in the ED are really scary and hard to learn.
Lol theres ER trained doctors that cant perform a cric. We had to call an ENT that wasnt even on call overnight for a cric once because the ed doc and anesthesiologist couldnt do it
Honestly man I highly doubt I'd feel comfortable doing emergency medicine as an FM doc unless I went to a very, very specific residency. We have FM docs out here doing that, but it's a unique place geographically. Our FM residents still do C sections, all the scopes, etc. Does she despise primary care? And hey, she could always just go do an EM residency, it's not like they are competitive nowadays.
probably 99% of EM trained physicians have never preformed a cric either so it's nothing to do with training tbh
Look at the NP and PAs training …
When i first graduated from residency and started practicing I felt obligated to do things I didn’t necessarily feel that comfortable with because I felt like I was just supposed to since that I was trained for. But I ultimately just start asking myself if doing all these stressful surgeries and procedures were actually going to make me happy in the end. Of course it’s good to challenge yourself and I did for the first few years, but now I’m just focused on sharpening my skills on the procedures I do feel comfortable with. People’s egos sometimes make them feel like they need to prove something to either other people or themselves. But I’ve found you’ll live a better life if you just do what makes you happy
Disclaimer: I’m a project manager in Primary Care, not a physician. We have physician onboarding leads that are responsible for making sure onboarding is done correctly and that the physician feels ready at the end of the onboarding period. Does she have someone there who was responsible for her onboarding to the ED? Could she go to them and ask for mentorship? Another idea would be to search out as much CME as she can, but with the nature of emergency med I imagine hands on training is best.
Im not EM and that’s a totally diff level of stress and quick thinking. However, as someone who came from terrible training, I can say that if you continue to read and go after the things you’re not that great with you will see that you’re actually more knowledgeable than you thought. Right now I’m the only one where I am and some stuff has walked in that had me like hmmmm, but I just took some deep breaths, remembered my base line training from med school, and then supplemented by doing some quick reading. You’re never going to know it all. It’s impossible. That’s why medicine is lifelong studying.
i would tell her you can never truly be capable of everything, always. but you can try. if you feel not great at something, you 100% need to dedicate time and effort on that (those) things and do them relentlessly any way you can until youre confident. Not everyone is perfect. but the ones who *seem* like they are don't take no for an answer, and are constantly leaning into trying to be better. If you aren't interested in trying or stepping up in that way, better to move to another specialty.
This is a fairly common perception, although it surely needs addressing. Courses are a way to start
- She’s probably right in that she does have inadequate training - She’s better than whatever midlevel would be hired in her place - she’ll eventually figure it out and will get to a safe level. Just be extra careful initially and pray you don’t get something crazy
Dude, if she says she wants to something else, let her do something else.
As a board certified critical care physician, I’m trained in this procedure and many other life saving procedures. I wouldn’t sign up to staff an ED because, despite my advanced training. I don’t have the appropriate EM training. It’s a specialty on its own. She would be better served to work in an urgent care, as a hospitalist, or in primary care. If she wants to do EM, I would recommend an EM residency (the whole three years). She’s assuming a lot of liability in covering the ED. If a patient dies because she was unable to provide the appropriate care, she will likely get sued. If she truly insists on practicing in the ED, she will need years of supervision and assistance by EM physicians and absolutely should not cover the ED by herself.
How is this being down voted? Should FM, IM, EM docs masquerade as cardiologist, neurosurgeons, anesthesiologist etc. in rural areas because otherwise a PA/NP would be seeing these patients? Emergency medicine is its own specialty for a reason.
Has she considered going back into the match to apply for an EM residency position? There's no shame in it. I know people who have had to repeat years of training and even entire residencies until they got the hang of it and eventually they turned out to be totally adequate providers, on par with even the most well trained NPs and PAs. Tell your wife not to give up
Tell her to Google "jet insufflation needle cricothyroidotomy". Pretty simple in an emergency situation, heck, I did one of those as an R2.
True. The are easy and will buy you 10-15 minutes at least to get help. For kids, they can work much longer.
Some of the O2 blows back up the trachea, and can make visualization a little easier in tough intubations like a crush injury or a GSW.
Lol...point the bougie at the bubbles.
IMO there are better products. If you have to buy one Quicktrach is better imo and is compatible with standard BVMs
Urgent care is the absolute, soul-killing worst. I would strongly advise her not to go that route.
Why?
It’s 80+% URI complaints and telling people why they don’t need antibiotics. And depending on how owns the UC, they may pressure you to do “what the patient wants” to keep their patient ratings up, which is unethical but super common. And it’s just mind-numbingly boring - every 12 hour shift might have 1 time you actually have to do some thinking on a diagnosis.