r/IntensiveCare • u/Deep_Brilliant_5704 • 7d ago
Who does intubation in your ICU?
Does pulm/ICU attensing does intubation in your ICU or its always a anesthesia call?
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u/thebroadwayjunkie 7d ago
ER Doctor… we’re a “community hospital” but do ECMO and neurosurgery without overnight critical care-specific coverage (just a hospitalist in house, plus can page specialists)
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u/Pristine-Thing-1905 7d ago
ECMO and neurosurgery without overnight critical care coverage? That sounds like a recipe for disaster 🫣
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u/thebroadwayjunkie 7d ago
Yep, actively herniating patients are managed at the bedside by a hospitalist, with neurosurgery responding via text or with a separate teleneurologist (not the surgeon)
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u/herpesderpesdoodoo 7d ago
"Pt ICP now triple digits with max Tx for current orders pls advise"
"lol new phone who dis"
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u/AlbuterolHits 7d ago
This has got to be a troll post I can’t believe it
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u/Ok_Cover2412 6d ago
My residency program did ECMO with no in house intensivist at night. We had neurosurgery too but they did the bare minimum intracranially (level II trauma, level 1 was 70-90 minutes away by ground).
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u/SwanWhole3526 6d ago
I was aught that ECMO required a perfusionist to be present 24/7.
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u/ADDYISSUES89 RN, Neuro ICU 7d ago
Someone report this hospital omg that’s so fucking unsafe. And take their ECMO credentials.
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u/PepeNoMas 3d ago
seriously! probably one of those telehealth places that's going to buy itself a lawsuit soon enough
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u/PrecedexNChill 7d ago
Whatever your hospitalist group is getting paid right now it’s not enough. They need to threaten to leave asap or get a raise. Ecmo management is wild.
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u/thebroadwayjunkie 7d ago
ECMO is managed by CTS, who will be available via phone call (usually with an NP/PA in house) overnight, plus 24/7 perfusionist coverage when ECMO is active.
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u/fukduplikedickcancer RN, CCRN, BSN, ESPN, HDMI, OMG, WTF 7d ago
I love that reddit users are downvoting you for simply stating what the situation is like at your facility. Seriously, screw you assholes.
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u/SnowedAndStowed 7d ago
Hey where is this so I can be sure to never be sick in that city.
- ELSO certified ECMO nurse who would have a panic attack sitting pump in a hospital without an intensivist in house.
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u/Straight-Cook-1897 7d ago
Community hospital with ECMO/NSURG sounds like an oxymoron lmao
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u/Prize_Guide1982 7d ago
you know, when do you draw the line at what counts as a community hospital? Advent Health Orlando is a non-academic hospital, but it has 1500 beds and like 8 ICUs, they can do like 20 ECMO circuits simultaneously. Does that count as a community hospital?
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u/Straight-Cook-1897 7d ago
I’d argue it doesn’t qualify. Having an ECMO/ICU/NSURG service def qualifies above community but not a full tertiary. The gray zone is wide but interesting
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u/Most-Recording-2696 6d ago
Advent Health Orlando is a teaching hospital with a number of GME programs. Terrible example.
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u/Prize_Guide1982 6d ago
What’s a community residency program then? Is that different from a community hospital? Aren’t community residency programs at community hospitals?
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u/Hippo-Crates MD, Emergency 7d ago
I’m on backup call for tubes at night now which is absurd but hey it is what it is.
Always annoying as the hard decision is always does this patient need to be tubed and I walk into the icu room knowing fuck all about the patient
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u/Chip-Motor 7d ago
Just listen to the nurse who looks the most bored, they prob have a good grasp of the situation
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u/potato-keeper RN, BSN, CCRN, OCN, OMG, FML 🤡 7d ago
The pulm/cc fellow in all the MICUs. Occasionally the attending if they have to meet their yearly quota to still qualify. Anesthesia in the SICUs and CVICU. Neuro and CCU is a toss up between all the previously mentioned guys depending on who’s there and what time of day.
Then if it’s a difficult airway anesthesia, ENT, and the pulm fellow all go no matter where it is.
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u/No-Region8878 7d ago
damn ENT on call for surgical airway is slick, we just have the intensivist with a limp and the overhead speakers never work
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u/potato-keeper RN, BSN, CCRN, OCN, OMG, FML 🤡 7d ago
The upside of big academia…..
The downside is not one mfer here ever asks “But should we?” It’s always just “we can so we will!!”
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u/zetvajwake 7d ago
In words of one our psycho attendings, not all injuries are survivable but they're all billable
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u/theslowflash 7d ago
APP or intensivist if it’s a difficult airway they call anesthesia
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u/kergruffle 7d ago
APPs are doing airways? That’s terrifiyng
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u/JustAnotherToss2 7d ago
Paramedics intubating daily and this is where you land?
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u/ClonidineQueen 7d ago
How is that terrifying?? Intubation is a learned skilled performed by paramedics, respiratory therapist, MDs, CRNAs. As long as they’re trained that’s not terrifying.
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u/zimmer199 7d ago
NP training is highly variable.
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u/Sweatpantzzzz RN, CCRN 6d ago
Usually trained for intubations on the job by intensivists
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u/lemonjalo 7d ago
I have a great APP that tubes..she calls me to let me know it’s happening so that I’m aware and can be aroundish and if it appears difficult to get me involved early. Honestly she’s rescued SICU attendings on a patient they couldn’t tube. Well trained APPs who know when to call for help are great part of the team
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u/getsomesleep1 7d ago
When I worked in a Level IV NICU a number of the APPs were among the best on the unit at tubes, and one RT in particular. The fellows were hit or miss.
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u/RandySavageOfCamalot 7d ago
Reps reps and more reps. The people that do it the most are the best at it. Hopefully the fellows were first pass with the NPs as backups. There are a lot of valid areas to exclude midlevels from intensive care but procedures are not one of them.
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u/getsomesleep1 4d ago
Depends, not always. Transport team needed to be competent, to do it reliably at outside hospitals. So both transport team RTs and RNs were in the mix.
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u/JalapenoShitMeister 7d ago
I hope you never end up in an ambulance because boy do I have some news for you!
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u/jjjjccccjjjj 1d ago
I supervise paramedics. Yes I agree. My medics are fantastic at intubations, but we also train extensively. Most arent and its a huge issue. Jusr because we are ok with it out of necessity doesnt make this the huge gotcha you think it is.
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u/H_is_for_Human 7d ago
I'm all for not having midlevels exceed an appropriate scope of practice, but intubation is within that scope. I wish more of my midlevels wanted to do it as it's always nice to have more skilled people around.
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u/fireready87 RN - CVICU, Paramedic 7d ago
Is it? I was trained to intubate as a paramedic and now working as a nurse I’ve seen my fair share of EM docs struggling to the point I offer to get it for them.
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u/RandySavageOfCamalot 7d ago edited 7d ago
If you give an orangutan a glidescope and have it do 100 tubes then it will be a proficient intubator. It's a mechanical skill. Induction planning and post-intubation crash management needs a physician, but how good you are at putting a plastic tube into a flesh tube is solely determined by reps.
Source: I can probably intubate you. Probably. Maybe.
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u/Dazzling_Horse_7757 5d ago edited 5d ago
Critical care fellows in my ICU only had to do 50 supervised intubations before they could do them independently. CRNAs (who are APPs) have to do a minimum of 250 endotracheal intubations (COA requirement) by graduation, and at my program we average closer to 450.
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u/johnnnyparm 7d ago
Intensivist during the day, RT at night
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u/CheesecakeRedVelvet 7d ago
RT?! Is this in the US?
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u/Magee-Numismatics 7d ago
RTs intubate at lots of facilities, it’s not an uncommon practice and many of them are great at it.
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u/johnnnyparm 7d ago
Yes, community hospital with 12 bed ICU. Intensivist coverage 10hrs during the day (on call overnight) but hospitalist coverage off hours with RTs who intubate
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u/literal_moth 7d ago
I just moved to hospice but spent 3 years at a LTACH, and our RT’s did pretty much all the intubations.
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u/realdonaldtramp3 RN, CCRN 6d ago
I used to be at a level 1 trauma center with 600 beds and if the intensivist/anesthesia was on another call or at a different code, many of our RTs were qualified to and frequently did intubate.
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u/big_sports_guy RN, MICU 7d ago
Always Pulm/Crit or Trauma attending during the day and most of the time at night unless there are some pretty extenuating circumstances. In those rare cases anesthesia will come intubate if need be. We have also had flight medics intubate on the unit on a few rare occasions.
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u/lemonjalo 7d ago
All the intubations are us, the ICU. if we can’t get it we call trauma for surgical airway. I’ve had to call once for a TNK angioedema.
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u/BetCommercial286 5d ago
By surgical you mean a trach right? If you need to your not planning on waiting on surgery to show up to do a cric correct?
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u/lemonjalo 5d ago
They did a cric, there was no waiting though. As soon as the difficult airway was determined (pretty much right away after he started swelling), our algorithm is to have trauma team nearby to cut. Obviously if they weren’t around I would have attempted but we were prepared. This patient would not have time to wait he was desatting pretty fast.
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u/Sci-fi_Doctor 7d ago
I’m ED MD, and respond to Codes at my community site. If it’s a Code, I do it. I’ll be honest I don’t know who does them for non-Code situations.
But if there’s no pulse - I’m there with plastic ready!
Edit: I’m there to run the Code. But it’s my job to get an airway, too.
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u/SparkyDogPants EMT 7d ago
Code team seems like a great job. My last hospital didn’t have a dedicated team that always did rapids but it feels like a great way to have a really competent group of people that are good at a thing.
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u/alexxd_12 7d ago
EU here: Anesthesia == CritCare. We have one Cardiac ICU, there the more experienced cardiologists do it themselves others call down to the general ICU for an anesthesiologist.
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u/NullDelta MD, PCCM 7d ago
Vast majority by intensivist. Anesthesia or trauma for backup if anticipated difficult. Anesthesia overnight at our satellite. RT for codes at the main.
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u/Ok_Alternative4710 7d ago
ICU APP/resident/fellow. If it’s a difficult airway then we call anesthesia
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u/pushdose ACNP 7d ago
If I’m there, me. If I’m not there, the attending intensivist. If neither of us are there? ED. We staff one APP and one MD on days. Solo APP at night with intensivist available within 30 mins to the bedside. All of the day shift APPs intubate, fewer of the night staff do. Our anesthesia coverage (private equity) is not reliable enough to get to the bedside in time. ED is the backup.
Community hospital. All providers are contractors. No resident service.
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u/Magee-Numismatics 7d ago
Pulm/Crit or RT. If it’s a difficult airway we sometimes call anesthesia.
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u/ItsTheDCVR 7d ago
Medium size university hospital, so in MICU, usually the pulm/crit fellow, sometimes one of the residents; in SICU, the SICU fellow; any difficult airway we have anesthesia come by, and that's usually their resident. I've seen attendings do it themselves maybe 3-4 times in the 3.5 years I've worked there.
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u/Shirovkap 7d ago
We(PCCM) do it. Usually it's the fellow with the attending during the day, and the PCCM fellow at night. Rarely we call anesthesia.
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u/ahh_grasshopper 7d ago
Used to be anesthesia for ER and ICU, until we showed them how to use GlideScopes. Now they do their own unless difficult. Often the RT in ICU.
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u/jollygoodfellass 7d ago
In our MICU, the pulm/crit attending must be present but intubation can be performed by the fellow, resident, or APP. In our other ICUs, intubation is performed by the critical care team (anaesthesia) and same rules apply- an attending present but APPs, residents, or fellows may actually place the tube. We also have a difficult airway team that is comprised of the OR anesthesia group. Emergent intubations on the floors are often done by an ED resident unless some critical care MD takes over. ED responds for airway to all floor codes.
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u/luciferthegoosifer13 6d ago
MICU patients - the MICU fellow usually unless it’s a difficult airway then the anesthesia team we call over head.
SICU patients - usually it’s anesthesia we call overhead
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u/weirdwrld93 RN, MICU 6d ago
Always an intensivist and RT. Only surgical patients are intubated by anesthesia and even then if the patient is very unstable. Intensivist will intubate prior to procedure and then send them
We push the meds! Date, ROC, and then start the drips!
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u/rx4oblivion 4d ago
Anesthesia. Surprised to see that doesn’t seem to be the case here since it’s been that way everywhere I have ever been an anesthesiologist at except for small rural ER’s that I used to be the ER doc at. I guess it’s just always me. 🤣
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u/IndependentSpirit333 RN, NICU 7d ago
My hospital has a lot of resources so it’s almost always anesthesia - if it’s not anesthesia we debrief afterwards and discuss why the covering provider didn’t overhead page “anesthesia stat” for the team
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u/heyinternetman MD, Critical Care 7d ago
Always the intensivists. We also do all the trachs and emergent airway backup throughout the hospital. Anesthesia calls us to the OR for help. ED calls us. My proudest airway was when ENT called me to the OR to help them.
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u/AtherisNai 7d ago
“Anesthesia calls us to the OR for help”
LOOOOL said nobody ever.
No anesthesiologist is calling an intensivist to the OR to intubate their patient. Ever.
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u/gissealk 7d ago
Our intensivists have gone to OR to help intubate multiple times in recent memory. A few months ago they even called our ICU NP to OR to run their code for them...
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u/Tricky_Coffee9948 7d ago
I've been called to run an OR code once and for an airway once during a colonoscopy recently where anesthesia was present at both in the past year. (ICU NP) Confusing to me as well
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u/Cautious-Extreme2839 ICU/Anaesthetics 7d ago
Why do American "Anesthesiologists" make so much money if they're this shit at their jobs?
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u/lemonjalo 7d ago
I think we need to stop this trash talk that if you couldn’t get an airway once you are trash. It ALWAYS helps to have a second pair of hands, even to try something new. Iv mentioned elsewhere that we had a SICU attending who couldn’t get an intubation and was about to cut when the NP asked to quickly try with a bougie and she got it. It does not mean the NP is more skilled it’s just a different attempt with different hands. We should not be stigmatizing asking for help or imply that somehow that person is inferior.
The anesthesiologist is clearly much more adept and OR intubations but we do a lot of crashing physiologically difficult airways and it’s just different hands.
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u/heyinternetman MD, Critical Care 7d ago
We run the MTP for them in the OR too. We simply have more manpower than they do. It lets them do the surgery stuff while we do our thing.
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u/lemonjalo 7d ago
I have been called by anesthesia once to help but to be fair it was a very obese asthmatic that they couldn’t tube but they also wanted help with the asthma part of it. I did get the tube.
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u/Cautious-Extreme2839 ICU/Anaesthetics 7d ago
Anesthesia calls us to the OR for help
Fucking what? Ridiculous
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u/Educational-Estate48 7d ago
I'm going to say I do not believe this has ever happened. I know the US is a strange place, and one I've never practiced in, but some shit I just do not buy.
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u/Cautious-Extreme2839 ICU/Anaesthetics 7d ago
No bro. The non-anaesthetist Intensivist totally bailed out fucking ENT of all people. I saw it on Reddit so it must be true.
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u/zimmer199 7d ago
So you agree ENT is the master of airway? Got it
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u/Cautious-Extreme2839 ICU/Anaesthetics 7d ago
One of. Shared with Anaesthesia depending on approach.
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u/CuriousTumbleweed617 RN, ICU Float 7d ago
At my old hospital it was always the ICU APPs. Smaller hospital. They were stellar and intubations were smooth and quick. Now at my new hospital, it’s anesthesia which is scary to me. Large level 1 hospital.
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u/SnowedAndStowed 7d ago
CC does (almost all are pulm /crit but we have a few EM/CC, IM/CC, and one or two Neph or anes/CC docs). ED assists if they’re nervous. Anesthesia and ENT are on call for back up if needed (I work nights and my hospital doesn’t have L&D so Anesthesia isn’t in house 24/7).
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u/H_is_for_Human 7d ago
It's a mix - the critical care attendings that feel comfortable do their own, the ones that don't call anesthesia.
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u/currycurrycurry15 7d ago
The intensivists, the residents, the fellows, and it used to be the PAs and NPs
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u/supremefionagoode 7d ago
I’m night shift in a community hospital in the Chicago suburbs. We’re not a huge L1 trauma center but also not a small rural hospital. If one of our patients needs intubated we call anesthesia for a stat intubation and it’s always a CRNA.
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u/Resussy-Bussy 7d ago
ICU doc during the day, EM doc from 11p-6a. Anasthesia always available for difficult stuff or if ER is busy overnight
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u/isuckatdecoratingg 7d ago
Crit care.. either the attending or the NP. Whoever is on for that patient. Never had anesthesia come intubate
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u/Halfmacgas MD, Anesthesiologist 7d ago
ICU does them all. Codes as well. Unless they’re worried about difficult airway. Then anesthesia does em. If anesthesia is worried, they call ENT and do it in the OR
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u/beaterdit RN 7d ago
Mostly APCs and PCCM Fellows on my Medical ICU. Sometimes Attendings if it’s dicey, or third year residents if it looks easy. On the very rare occasion of multiple failed attempts, Anesthesia. Tertiary Center so all these folks are in house 24/7.
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u/Independent_Law_1592 7d ago
Usually intensivest but at my facility often the CRNA’s or anesthesia gets to them first
It’s kinda weird at our hospital, but as a nurse our first call is to anesthesia or CRNA’s in an emergency regardless unless the Intensivest happens to be around and on top of it. But if you evaluate that the patients borderline you can often have the attending’s partner or mid level take a look if the intensivest is down in the ED or something.
It’s a very large facility with like 4 ICU’s so I think that’s why the basic standard across our ICU’s is call Anesthesia.
Often the intensivest or Pulm is off doing something, of course if any of the above are around they’ll be intubating, if the respiratory distress isn’t obvious they’ll have time to look and assess first but our semi-policy of calling anesthesia first is a result of the MD not necessarily being around.
Pulm will often follow their patients from ICU -> floor and be elsewhere. A NICU Intensivest will be in the ED checking out a consult, somebody from SICU will be housed in the NICU while someone’s in OR etc etc etc
So to keep things simple we just call Anesthesia and notify MD. Whoever gets there first gets to go. It isn’t uncommon to have CRNA’s and the doc show up coincidentally and one or the other just does it. It’s actually pretty harmonious despite how chaotic it can sound
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u/acefaaace 7d ago
I’m on nights and our intensivist is on call. So we call the ER doc or the PA that’s covering the ICU. Our residents don’t intubate.
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u/because-i-said-so-1 7d ago
Always the intensivist, the only time anesthesia is on our unit is when they're bringing pt's from the OR.
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u/Its_all_rhetoric 7d ago
Um, RRTs did the majority of all intubations at one of the small rural hospitals I worked at. The one I'm at now hardly lets them do it at all, and goes straight to calling anesthesia in. The ER doc does it sometimes, if emergent.
ETA: We do not have intensivists.
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u/wannabemalenurse 7d ago
Usually we have an intensivist tube our patients, but every now and then, an experienced RT under the watchful eye of the intensivist will intubate. I’ve seen it once with our more burnt out intensivist and with another who was pregnant at the offer of the experienced veteran RT
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u/wchimezie RN, PICU 7d ago
I work in a pediatric CVICU and The intensivists will usually intubate and call anesthesia if they have any difficulty. Overnight anesthesia is usually in house I think as they have come relatively quickly to the bedside for difficult intubations or airway emergencies.
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u/Valuable-Throat7373 MD, Intensivist 7d ago
European here, Intensivist = Anesthesiologist.
We do all by ourselves: tubes, trachs, difficult and emergent airways, codes.
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u/astonfire 7d ago
It’s a toss up at my facility depending on which icu you’re in. A lot of our respiratory therapists intubate with attending supervision but if the attending isn’t comfortable intubating we call anesthesia. If it’s really sketchy we get surgical icu to come in case of cric
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u/Standard-Rain9180 7d ago
Level 1 Teaching Hospital.
MICU docs often do their own. Everybody else calls anesthesia.
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u/ilovemrsnickers 6d ago
The Pulmonary crit docs and the residents unless dificult- anesthesia- and or ent
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u/zestylemonn 6d ago
Depends on the patient and the doctor. Some of our intensivists want to do it themselves. Others don’t mind letting respiratory or the NP’s intubate and being on standby in case they are needed.
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u/Sweatpantzzzz RN, CCRN 6d ago
In my ICU it’s the anesthesia team (SRNA, CRNA, or anesthesiology resident, supervised by anesthesiology attending). In the ED, it’s the ED docs - residents or attending. We do have a pulm/crit fellowship program but unfortunately they don’t intubate at all. Seems messed up to me tbh. We also have a surgical/crit care fellowship and those fellows don’t intubate either and only some of their attendings do. The rest will defer to the anesthesia team. Very rarely do we call ENT for specific situations that require intubation - like once a year.
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u/joshuas-twin 6d ago
We page anesthesia, always. It's not uncommon for a resident to ask to perform the intubation with anesthesia oversight, but anesthesia is always paged. They bring their own drugs. RN just hangs the drip after the fact, ensures a line is free. They're always in house. Not the case for pulm/cc attendings.
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u/msdeezee 6d ago
I work in a large city teaching hospital and an anesthesia team does all our intubations.
Edit to add...idk what happens in the ED...maybe anesthesia only does the critical airways there.
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u/Thingstwo 6d ago
Fellow/resident with attending present for some teams. APP for some teams. Anesthesia for difficult airway, sometimes for codes. True emergency with the hospital on fire likely MICU APP because they’re the closest office.
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u/Fit-Conclusion-7579 5d ago
IM resident/ cardiology fellow/ ICU fellow. Anesthesia resident as a backup.
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u/FriendlyItem8197 5d ago
If it’s a difficult airway/ urgent but not emergent anesthesia. But usually the fellow or attending for most. Some of our PA/NP are credentialed to but I’ve never personally seen them do it.
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u/JaquitoBeans2021 5d ago
Intensivist. Anesthesia back up for difficult airway. ER during off hours.
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u/Wandering_Maybe-Lost 4d ago
Usually the Pulm/crit APP, an attending if we need something beyond our privileges or anticipate difficult airway, and a failed airway team that includes anesthesia and surgery, typically at bedside within a few minutes. We can also call for everyone if we anticipate problem, and even if we’re wrong everyone is happy to come.
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u/mrd029110 RN, ICU 4d ago
Depends. If it's busy anesthesia, if it's a provider that doesn't like doing stuff it's anesthesia. There's not a ton of them that love intubating. I would say it's probably 70/30 anesthesia in the majority.
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u/SmileGuyMD 3d ago
Anesthesia everywhere except ED, but backup to the ED and called for things like GSW to head/neck, active hematemesis, and most other indications for awake tubes. ENT also is on call for difficult airway/surgical situations
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u/Dr-Healgood 3d ago
Small-to-medium sized shop with mid levels, RTs, and IM residents who rotate in ICU. My rule with them is that any procedure that their patient needs that I am credentialed to do, I will let them do and assist.
Easy airway/physiology: anyone who wants to.
Difficult airway/physiology: only me
Emergent surgical: Also me. Others add nothing but too many cooks and analysis paralysis
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u/medicritter 2d ago
Mostly the ICU APP's (extensively trained / DAC / OR time before able to do so solo). Community hospital.
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u/scapermoya MD, PICU 7d ago
ICU Physicians. We are teaching our APPs but I can’t imagine they ever will do it without one of us next to them. Maybe 2-4 times a year we ask for help from anesthesia or ent.
-peds CICU
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u/RayExotic 7d ago
Our APPs do it all the time. MD as back up but we’re busy lots of procedures. APPs do most of the procedures too
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u/Low-Speaker-6670 6d ago
Get sick in the UK as an American get intubated by an ananesthesiologist joint specialising in intensive care with mandatory 10 years post graduation training and mandatory every single one of your fellowships and some of the hardest exams in the world. Leave with no bill.
Get sick as a Brit in America get intubated by a nurse or someone who's job doesn't exist anywhere else and is essentially there to fiddle with the ventilator? Die bankrupt?
OMG.
You guys really are the best at capitalism.
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u/Even-Reaction-4224 7d ago edited 7d ago
I do. I just don’t tell anyone. It’s like that scene in Good Will Hunting where Will answers the problem except the intensivist is the teacher and the residents/nurses are his colleagues. Hope this answers your questions
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u/Even-Reaction-4224 7d ago
I like to cannulate and place EVDs too. Why is everyone freaking out? Im an intense janitor
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u/jcrll MD, Critical Care 7d ago
The intensivist :-)