So I've been having one of those funky runs of call in which it seems everyone crashes on my watch. Patients who were as stable as can be on the previous shift suddenly become obtunded or oxygen-starved the minute I've gotten sign-out and the other hospitalist(s) have left the building. This happens to everyone--after all, the patients are in the hospital for many reasons, one of which is the risk of getting sicker--so I'm trying hard not to take it personally.
Anyway, the upshot of all this chaos is that I had to intubate two patients this month, which is more than I've done in the past five years. I haven't been the point person for intubations since I was a second-year resident covering the ICU and NICU. When you're a resident, you'll intubate anybody, just to get the practice. (This is the only reason to hang around the OR or ER, in my humble opinion--to pick up experience in managing airways.)
The thing is, once you become a real doctor, your priorities shift and you start doing everything in your power to avoid intubating patients--unless you become an anesthesiologist or an emergency physician, the former having committed herself to the vagaries of expertise in airway management, and the latter exposing herself to the slings and arrows of whatever shows up during her shift in the ER. The rest of us leave residency and realize the path to respiratory failure is paved with opportunities to stave off intubation, such as well-timed discussions about the limits of care, prompt initiation of noninvasive ventilatory support modalities such as BiPap, and frequent patient assessments to make sure you've got the right diagnosis and are managing the problem aggressively.
In fact, avoiding needless or futile intubation is a much more complex and difficult art than getting an endotracheal tube past the vocal cords. I'm not saying intubation and mechanical ventilation are bad things, but they are invasive and probably not appropriate for every patient, so it behooves a hospitalist to anticipate problems, communicate effectively with patients/family/staff, and deploy alternative therapies appropriately before rushing to the bedside with laryngoscope in hand.
Having said all of this, sometimes the deck is stacked against you and you have to intubate a patient who is deteriorating. Suddenly, all the expertise you've developed in avoiding intubation makes you feel a bit rusty. You start to wonder if you should call the anesthesiologist to get the tube in, because she's better at it than you are and you don't want to fumble with the tube and the scope in front of all the staff.
If you're a rural hospitalist, you might not have an anesthesiologist available to intubate the patient, and maybe the ER doc is tied up with a crisis of her own, so all eyes are back on you to get the job done. Fortunately, a few factors are very much in your favor:
1. Kinesthetic memory is a wonderful thing. Once the tube is in hand, the memory of all those R2 intubations come rushing back and the next thing you know, you're looking at the vocal cords and are as amazed by their space-alien beauty as you were the first time you saw them, all those years ago.
2. Technology has improved by leaps and bounds since you were a resident. Of the two intubations this month, I had a GlideScope available for one, which was a real Far Side Caveman moment for me. Instead of struggling with a stainless-steel laryngoscope and worrying about dislodging teeth, there I was holding the video baton and rocking the plastic introducer back just enough to see the cords on the portable video screen. A piece of cake. A monkey could do it, assuming it passed gross anatomy, and if I passed I'm pretty sure a monkey can too. The GlideScope is going to be a huge boon to the rural hospitalist, especially in dreaded Weird Jaw and Neck From Hell scenarios.
It's like falling off a bicycle. Thank God.
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