> I don't intubate often. Probably much less often than most
> members of this
> list. When I do it is most often in our small emergency dept
> which is
> staffed by a single nurse. (we always try to get other
> nurses/docs in when
> time allows of course).
>
> I work a 1 in 3 in our rural community and there is no provision to
> backfill me if I were to want to go and grab a few tubes in the city.
>
>
> That fear, for me at least, is best managed by the thought
> 'what do I think
> is the best thing for this person?'
>
> But...
> What if I don't have my number of requisite intubations? And
> don't have my
> certificate? (we don't have a requirement but I pose the
> question as if in
> the UK)
>
I'd approach it from a different direction. When it comes to the situation, you do whatever you think is best. However, if you think that there is a realistic likelihood of your getting into a particular situation, you need to be prepared for it. Kind of like if it came to the crunch, I might to a cricothrotomy or thoracostomy with a penknife and ballpoint pen, but if I was going out to a situation where I thought I might have to do it, I'd be expected to have the proper kit with me.
In this case, it sounds as though doing the occasional RSI is part of your job that you do on a fairly regular if infrequent basis. If that is the case, you need to ensure that you are up to speed with your intubation. If you're not up to speed, you need to flag this up as an issue and raise the point that you are not adequately qualified to do the job you are needed to do. Backfilling may well be tricky, but what happens when someone is away on holiday? Do you take any study leave at all? What I'd guess you should be doing is once every so often (once a month? Once a quarter? I don't know) have a scheduled day when you go to the city and get some RSI experience in a controlled environment together with feedback on your skills; and make this part of your job description.
I'm not too tied down on certificates. What is more important is skills. And if you're not doing enough, chances are you don't have the skills. You may not be far off it, but if something goes wrong with a RSI it goes very very wrong and in your case there's nobody to bail you out.
> The question might be extended to 'and what if docs stop
> doing pre-hospital
> care because of requirements that are too difficult to meet?' - and
> perhaps also to 'what about the patient that dies for want of
> a secured
> airway'.
I don't know the answer to that one. Maybe care would be better, maybe care would be worse. Put the question a different way it could be "What if docs with inadequate experience in RSI stopped doing it in circumstances where they lacked any backup and started switching to good quality basic airway control and getting the patient to someone with more skills as quickly as possible". An analogy could be with emergency repair of abdominal aortic aneurysm in the UK. A few years back the question was "What if general surgeons stopped doing these because of lack of ongoing experience and what if the patient died due to a longer transfer to a centre with a vascular surgeon?" On the airway one, some patients may die because of unsecured airway; some lives may be saved because of avoidance of missed oesophageal intubation and "can't intubate, can't ventilate" cases.
Overall, my first line would be to forget about credentialling, but to ensure that you are up to speed with intubation (and in an isolated unit with no backup, that means pretty good) and make it clear to whoever is running the hospital that at present your skills are not up to what is needed for this part of the job.
Matt Dunn
Warwick
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