For the case intro, See “Let the Junior Intubate? Nah… (Part A)”
In an earlier post I introduced a case that got me thinking about intubating in a training environment. Specifically, I wondered, how do we decide whether the junior-most or senior-most person in the room should intubate the patient with impending respiratory failure?
O (Big) Brother, Where Art Thou?
When it comes to resident intubation there doesn’t seem to be much guidance from major US EM organizations – CORD, ACEP, SAEM or AAEM. CORD doesn’t say anything on its website and ACEP’s intubation and training policies focus on billing & documentation. Though SAEM addresses the issue of student supervision in its Ethics Curriculum it does not offer guidance on gauging resident proficiency in critical procedures. And the newly proposed Emergency Medicine Milestones help a little, but they cannot be directly translated into practice recommendations (specifically, “PC10. Airway Management”). Even the ACGME’s Emergency Medicine Program Requirements are vague on the subject.
Though concerning, a lack of instruction from professional organizations is not surprising. Given the varied practice environments and teaching styles across the specialty we are left to our own devices to come up with an answer to the question, “Should the junior resident intubate?”
The Ethics of Trainee Intubation
- Beneficence (Remember? You love helping people.)
- Non-maleficence (First, do no harm.)
- Distributive Justice (Equal distribution of risks and benefits)
- Patient Autonomy/Self Determination (In the U.S., the patient almost always has the final say)
- Stakeholder Perspectives –
- Patient: The patient who declares “I don’t want students taking care of me!” thinks she will get better care by avoiding trainees. While some people believe that trainees expose patients to an increased risk of harm there are others who claim that patients actually benefit from the increased attention paid to them by supervised students and residents. Nonetheless, in the name of Autonomy, physicians must generally respect this request. Firstly, we often do not properly inform patients that some of the care in academic centers will be provided by trainees (an a-priori violation of patient autonomy and self-determination). Secondly, even if the patient provides truly informed consent, he may rescind it at any time. And yet, by refusing trainees the patient is standing in the way of Distributive Justice; all patients should be equally exposed to the risks and benefits of trainee care, not that this is of any concern to the individual. Finally, it is the physician’s duty to ensure that the person performing the procedure is skilled enough to do so safely in the interest of Beneficence and Non-Maleficence.
- Learner – Needs to establish proficiency in Emergency Medical procedures while upholding all four patient and society centered values.
- Educator – Must supervise the learner while encouraging professional growth. Simultaneously, he needs to continue his own personal growth by managing more complex situations while upholding all four patient and society centered values.
- Society: There is little doubt that society as a whole benefits from trainee care. By allowing physicians in training to provide direct patient care society is guaranteeing that everyone will have access to experienced, well educated physicians. Unless we all conspire to kill and maim the people under our care, there is little risk of trainees violating the values of Beneficence and Non-Maleficence, as pertains to society itself. And short of continuing training despite society’s demanding that we stop, it would be hard to see how medical training would violate society’s right to Self-Determination. However, Distributive Justice is a little trickier. The benefits and harms of trainee care should be distributed equally across the entire country and through all strata of society and yet data suggest that people who receive care at training institutions are more likely to have Medicaid (public insurance intended for those who cannot otherwise afford medical care) and be non-white. Also, the EP’s decision to intubate carries with it significant consequences. Intubation commits a patient to mechanical ventilation and possibly an ICU bed. Since the requisite specialized nurses, respiratory therapists, vents and beds are all finite resources, this one decision has the potential to impact many other critically ill patients. The situation becomes even more complicated when the patient is in the end stages of a progressive, terminal condition or when mechanical ventilatory support is deemed medically futile. In the U.S. Self Determination generally trumps Distributive Justice, and even clinical judgement, and thus physicians may feel forced to perform life-prolonging interventions that will have no effect on clinical trajectory at the expense of other patients. Thus, it is up to the supervising physician to guide the trainee through this murky ethical dilemma as well.
- The Hospital: The ethics of systems and institutions is somewhat different. The most relevant considerations in this context may be the hospital’s own exposure to harms and benefits through the involvement trainees in emergency medical care.
- Quality measures – Complications caused by inexperienced practitioners may directly harm patients, but even if not, they reflect poorly on the institution.
- Cost – Trainees may increase cost through unnecessary use of durable and disposable medical supplies related to inexperience, improper preparation, failed attempts, etc. Also, the presence of trainees may decrease speed or efficiency, increase cost of care, cost of malpractice insurance, or exposure to litigation.
- Prestige – The presence of training programs often increases an institution’s prestige in the eyes of the public.
- Revenue – Prestige may directly lead to increased referrals and patient volume. In the U.S. resident training is largely funded by Medicare (a federal entity whose primary mandate is the funding of medical care for those aged 65 and above). Thus, residents and fellows are a source of labor that may increase a hospital’s ability to care for patients that does not significantly drain a hospital’s primary financial resources.
The emergency medical provider must be mindful of all these considerations while considering the best way to stave off death yet again. And though consent is often assumed in true emergencies, questions of beneficence, non-maleficence, self determination and medical education must guide our care just as much as the clinical presentation itself.
A Little Help From My Friends?
From a patient safety perspective, some people I’ve spoken to insist that the most senior person in the room should always perform the intubation. Others, more focused on the learner, have told me that the junior-most person should do the procedure, provided that adequate supervision is available. The best answer, as always, probably occupies a happy medium between the two.
Lots of questions and no answers…
Trainees are in the ED to train and patients are there to get quality medical care. In the interest of balancing the needs of both, the junior-most person should be the one performing any procedure, assuming a few conditions have been met:
- The trainee has completed adequate RSI and AW training (as defined locally)
- The trainee has demonstrated proficiency using procedural simulators
- If this is the first time the supervisor and trainee are working together, the trainee is able to adequately verbalize RSI plans and contingencies with supervisor
- The supervisor is proficient in advanced AW management and AW rescue
- The supervisor has been trained in safely managing trainees
- Patient condition is appropriate for junior intubation
The first 5 conditions are self-explanatory. In the next and final installment of “Let the Junior Intubate? Nah…” I will summarize the first two parts and attempt to define, using clinical literature, which patients are appropriate for junior intubation and which should only be attempted by the most experienced clinician in the room.
All references will be provided in the final post.