As the hospitalist tried to position the portable video laryngoscope properly in the airway of the critically ill “patient,” HM19 faculty moderator Brian Kaufman, MD, professor of medicine, anesthesiology, and neurology at New York University (NYU) School of Medicine, issued a word of caution: Rotating it into position should be done gently or there’s a risk of tearing tissue.
One step at a time, hospitalists attending the session grew more confident and knowledgeable in handling urgent matters involving patients who are critically ill, including cases of shock, mechanical ventilation, overdoses, and ultrasound.
Kevin Felner, MD, associate professor of medicine at NYU School of Medicine, said there’s a growing need for more exposure to caring for the critically ill, including intubation.
“There are a lot of hospitalists who are intubating, and they’re not formally trained in it because medicine residencies don’t typically train people to manage airways,” he said. “We’ve met hospitalists who’ve said, ‘I was hired and was told I had to manage an airway.’”
“It might massage some of the things you’re doing, make you afraid of things you should be afraid of, make you think about something that’s easy to do that you’re not doing, and make things safer,” Dr. Felner said.
In a simulation room, James Horowitz, MD, clinical assistant professor and cardiologist at NYU School of Medicine, demonstrated how to use a laryngeal mask airway (LMA), a simpler alternative to intubating the trachea for keeping an airway open. Dr. Kaufman, standing next to him, clarified how important a skill this is, especially when someone needs air in the next minute or is at risk of death.
“Knowing how to put an LMA in can be life-saving,” Dr. Kaufman said.
In a lecture on shock in the critically ill, Dr. Felner said it’s important to be nimble in handling this common problem –quickly identifying the cause, whether it’s a cardiogenic issue, a low-volume circulation problem, a question of vasodilation, or an obstructive problem. He said guidelines – such as aiming for a mean arterial pressure of 65 mm Hg –are helpful generally, but individuals routinely call for making exceptions to guidelines.
Anthony Andriotis, MD, a pulmonologist at NYU who specializes in critical care, offered an array of key points when managing patients with a ventilator. For instance, when you need to prolong a patient’s expiratory time so they can exhale air more effectively to get rid of entrapped air in their lungs, lowering their respiratory rate is far more effective than decreasing the time it takes them to breathe in or increasing the flow rate of the air they’re breathing.
Some basic points – such as remembering that it’s important to be aware of the pressure when volume control has been imposed and to be aware of volume control when the pressure has been set – are crucial, he said.
The idea behind the pre-course, Dr. Felner said, was to give hospitalists a chance to enter tricky situations with everything to gain, but nothing to lose. He described it as giving students “learning scars” – those times you made a serious error that left you with a lesson you’ll never forget.
“We’re trying to create learning scars, but in a safe scenario.”