Should all med students learn how to deliver a baby or intubation? #meded
— Taylor (@canibagthat) June 13, 2013
And with that began a debate that might have deteriorated into an all out brawl had the participants been standing face to face. This came on the heels of yesterday’s excitement around the question of stopping clinical studies early for harm, but not for benefit (see Seth Trueger’s final thoughts on this at MDAware). Ah, FOAM, how I love thee.
Catch a baby or intubate? Two generally unrelated skills, unless one is intubating a neonate (not at all unlikely in the EM world, yet unrelated to the current discussion). The real question here is whether AW management via endotracheal intubation trumps baby-catching, or vice-versa, given the constraints of medical education.
In the onslaught of tweets that followed, Minh Le Cong, Steve Carroll, Seth Trueger, Taylor, Nicholas Chrimes, RivkaMD, Crystal Upshaw and I duked out the merits of each procedure. The discussion wandered, as Twitter debates often do, lost context, went off on a tangent, and then returned to the initial question. I don’t think we came to any conclusions, but Minh has promised us a poll. He has also kindly Storified most of the conversation here.
People’s comments really helped me reflect. And I’ll admit, I wavered for about a minute and a half. But if one must choose, I still think that delivering babies should be preferred to intubation for medical students. The reasoning doesn’t fit into 140 characters so I hope to spell it out a little better here, and perhaps to buy some converts.
- Catching babies is easy – My Ob/Gyn colleagues will (hopefully) forgive me. The delivery of a low risk pregnancy could be handled by virtually anybody with minimal training. Not that it should be, but it could be. A high risk delivery is an entirely different story, and immaterial to this discussion as it requires high levels of expertise that will not be available to the student anyway. It is possible, within the constraints of an ObGyn rotation, to teach a medical student to handle a simple delivery. Furthermore, maintaining proficiency does not require frequent repetition and practice. There are no complicated pieces of medical equipment to be handled, no special dexterity is required, and the common technique is generally a simple one. In the end, all we are doing is facilitating an entirely natural process.
- Catching babies is practical – It doesn’t happen every day, but on occasion babies are delivered on the street, in taxis, trains, buses, offices and other unexpected places. Our valets generally host 1-2 curbside deliveries per year. It is helpful, and rarely harmful, to have a physician around who may be able to help ease a woman’s stress in a very challenging time. Even minimal knowledge will bolster the doc’s confidence.
- Society expects it – If there is one thing society expects physicians to do, it is to be able to deliver a baby. Yes, we must be able to resuscitate in accordance with standard protocols, and everyone thinks we should auscultate hearts and lungs, hold hands, and be good listeners. But between intubation and delivery, intubation seems to be expected only of master resuscitationists while delivering a baby appears to be within the bounds of any purview (anecdotal, I do not have any data for this).
- Most students will never intubate again – Resuscitationists intubate. Some surgical specialties intubate. The vast majority of doctors will never need to perform invasive airway management. It is a procedure that should be demonstrated, and can be taught, but is in no way essential to a student’s medical education.
- Intubation is hard – Forget about RSI for a minute. I concede that we could standardize RSI to a degree that would allow any physician certified in ACLS to appropriately administer sedatives+paralytics. The problem is the manual skill. Laryngoscopy and intubation both require a level of dexterity obtained over time and maintained only by constant practice. A student can be taught how to intubate. He or she might even attain a level of proficiency over the course of a few weeks in the OR or the ED. And yet, once that student puts down the laryngoscope the skill fades and is eventually lost. To expect that student to pick up a laryngoscope five years down the road and successfully intubate a patient while maintaining expected safety standards is unreasonable. It may even directly harm the patient. How many unsuccessful tubes have you seen? Disaster, no? And then, going down the road of failed intubation, should this same student also be able to complete the VORTEX?
- You need equipment to intubate – Most of us do not carry scopes, tubes, suctions and BVM’s in our cars. Those of us that do are probably docs and medics who intubate on a regular basis anyway.
- Intubation is non-essential -Endotracheal intubation must be separated from general AW management which is an essential skill. If you are a doctor you must know how to assess, clear, and maintain an airway. But this can all be done via positioning, manual manipulation, insertion of oro-pharyngeal and naso-pharyngeal airways, and the use of laryngeal-mask airways. These techniques, together with appropriate ventilatory management, are almost always able to maintain adequate oxygenation/ventilation at least until the next level of care is available. Why risk killing a patient, or significantly impeding the advanced practitioner’s ability to intubate a patient, due to the clumsy efforts of an inexperienced provider?
- Intubation can be learned later – I wholly agree with the notion that earlier training allows for more practice and hence increased proficiency. And yet this logic only works for those who are going into fields of medicine that require advanced airway management. Exposing students to intubation is beneficial, but it does not replace formal AW training as a resident/fellow, etc. (including the entire continuum of contingencies).
In the end we are merely debating an interesting hypothetical whose answer won’t have implications for most of us. But the underlying question of which skills to teach in the short time we have with medical students is an important one. By way of generalization, perhaps answering the following questions can help guide future decisions:
- Is the skill easily learned, practiced and assessed during the rotation?
- Is the skill relevant to the rotation and is it part of the common practice?
- Is skill-specific proficiency retained or rapidly lost over time?
- Will this skill be useful to a broad set of medical students?
- Does this skill require specialized equipment not available outside common medical settings?
- Will teaching this skill expose patients to unacceptable risk?
- Would partial knowledge or inappropriate implementation confer significant risk to patients?
- Will this skill improve patient care in any way?
Medical school should prepare the student for further learning as a physician. It cannot teach every future doctor everything they need to know. The trick is to find the cut-off. It’s a balancing act between what’s cool and fun, what we (educators) love to do and think is important, and what students need to know in order to decide on a career path. Intubating is cool and fun, it’s essential for those of us who frequently deal with critically ill patients and it could influence a student’s choice of specialty. But, in the end, it is not a critical part of a student’s training since alternate AW management techniques abound, and the skill will be lost by all but a few. Catching babies, on the other hand, is also cool and fun, and can influence a choice of specialty. No, it’s not a critical skill, but it is one that everyone thinks doctors should be able to perform. And if you’re not going to learn it in medical school, you’ll not get another chance until that baby is ready to drop into your hands.