I don’t know whether it’s good for my patients or bad for me, but today was the first time I had to make the decision to intubate a patient. (Other times, the decision had already been made.) It was actually pretty straightforward: RN: “Alice, the patient’s sats are in the 80s, and I can’t make them come up.” Alice: “I see you have him on a nonrebreather mask and have been suctioning him. Sir, can you open your eyes? Can you talk to me? No. Ok, the sats are dropping further, let’s start bagging, let’s call anesthesia.” Done. It’s usually a bad sign when you can intubate without paralytics or sedatives. Then we spent the rest of the day trying to figure out which came first, the chicken or the egg: the altered mental status or the respiratory failure.
Next time, if the aggressive chief is around, we might skip the “call anesthesia” part. At this hospital, anesthesia residents are always available (although available might mean 10-15 minutes away, not always good in a less controlled code than this one was), so the intubations are almost always done by them. But the equipment is there in the ICU, and there’s something to be said for knowing how to intubate when you have to. Of course, there’s never a good time to learn. Where I went to school, there were no anesthesia residents, and the surgery residents were responsible for intubating any time a code was called, or for trauma patients in the ER – so they learned pretty quickly.
Also for the first time I supervised another resident putting in a subclavian line. I’d tried to supervise before, but my tolerance level for teaching on awake patients is still pretty minimal. We both did better with the patient intubated and sedated.
I think I’m turning into “friendly reference material” for the interns, since they can be pretty sure I won’t mock them if they ask questions. I’m afraid I’m also behaving like a mother hen, trying to help some of the weaker interns who are getting picked on. I’m not sure I’m approaching the situation correctly, and I hope that I know enough myself that my advice doesn’t end up getting them in more trouble. I also wonder whether my kindness doesn’t undermine the high demands inherent in surgical residency; eventually, patients will die if you make the wrong choices, and getting a harsh response to a stupid answer is only preparation for that. But I figure there are enough men around here who will provide that aspect, it shouldn’t unbalance things too much if some of the women adopt a gentler approach.