The Art of Intubation


Perusing other blogs and came to this entry on the Trauma Bay where an EM resident was describing how difficult it can be to intubate patients. During his first rotation in the operating room, he had a success rate of 9 for 13, or 69%.

The post made me think and it made me laugh.

As our country transitions toward non-physicians in the emergency departments, will the lack of training in certain procedures cause an increase in morbidity or mortality?

The flip side is that even some attending emergency physicians aren’t that good at intubating. That’s what made me laugh. I had to deal with one of those attendings once.

One of the attendings I worked with was a solid doc, but he couldn’t intubate for nothing. If a patient needed intubation, he called anesthesia. Oh, he’d try to get the tube in, but he hit the esophagus 95+% of the time. Would have been a great gastroenterologist. Everyone razzed him about it. Even people who had no idea what it meant to “intubate” someone. They just knew they could get under his skin about it. Sometimes he would snap and start screaming at people.

Finally it caught up with him. A family and a new EMT both complained about him to hospital administration in the span of a week – both about him not being able to intubate. I drew the short straw and had to figure out a way to diplomatically tell him that he needed to get some remedial training.

So one day when I relieved him on a shift, I told him I needed to talk to him about someting and brought him back to the doctor’s room.
“What, am I in trouble for something?”
“No. No. Nothing like that. But administration came to me and asked me if you’re having problems with your intubation skills.”
“What did you tell them?”
“I said that I haven’t seen you attempt it, so I didn’t have any direct knowledge.”
“So ….?”
“Well word is in the ED that you have trouble sometimes. What do you think about maybe doing a little time in the OR after a shift just to get some pointers on the more difficult cases?”
Bad day for that suggestion. His face got all red and he started screaming.
“You God$#@% backstabbing mother*^$#ing c%#$sucker!”
My jaw dropped.
“What?” I asked, still in shock.
“Um … I just asked if you wanted to do a little time in the OR. What’s that got to do with having your back?”
“Listen, you c#$@sucking sonofab#$%^! Are you going to support me or not?
“Sure. I always have supported you. So do I take that as a ‘No’ for the OR time?”
“F#$@ YOU!”

I went out into the ED to start seeing patients. He caught me off guard this time. I started plotting a way to record his next tirade – next time I would be expecting. That way everyone could laugh about it. Maybe I’d even put it up on YouTube.

Ten minutes later, he comes out of the doctor’s room eating an apple and nonchalantly says – as if nothing ever happened – “So you know when next month’s schedule is coming out?”

Lithium works well for bipolar disorder, bud.

Unfortunately, he didn’t stay with the hospital long enough for me to ever get him on video.


  1. Hmm. Maybe a better title for this post would have been “The Art of Personnel Management,” or, from the other perspective, “A great way to get yourself fired.”

  2. Gives new meaning to the phrase, ‘chip on his shoulder’. Obviously he felt this marked him as incompetent, despite all his other skills, otherwise he wouldn’t have reacted the way he did.

  3. The process of separating the wheat from the chaff in emergency medicine is clearly far from effective. Come the f*ck on. Should we tolerate 747 pilots who can’t manage to land the jet, or cops who can’t hit the target at 25 yards?

    The fact that you felt the need to soft-pedal this issue with him is remarkable. You are a spineless POS.

    A leader doesn’t ‘get the back’ of an incompetent subordinate. You should have had the guts to lay out your expectations and given him a date certain to either meet the ‘standard’ or get the f*ck out.

    Why do professionals tolerate this crap? Is the physician in question black, queer, or from some other oppressed minority ?? Did you give him a pass so that the ‘group picture’ would look more like America?

  4. Sad thing. He and the patients would have been better off if he had taken you up on your offer and learned to do it properly.

  5. Wow.
    What an over the top reaction, and completely unprofessional. I can sympathize with one of your concerns about non physicians in the ED. Which is why I push our department to let the PA students try and get some procedures in (besides suturing). One of the smaller ED’s I moonlight at, has no physician on duty-it’s too small, so the PA is often the only provider there. Intubation can be easy as cake with some patients, or extraordinarily difficult with others. I would urge others here to realize that PA’s will occasionally, and no, not ideally, but occasionally be in situations where intubation and other procedures may be needed. I would encourage the readers to please make sure to help educate and train PA’s and NP’s in regards to these procedures, you may be saving someone’s life someday.

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