Intubating Monkeys

“I could teach a monkey to intubate.”

Quick!  How do you feel when you hear someone say this to you?

How many times has this statement been uttered in your presence?  Is there any validity to it?  Does the statement elicit any sort of visceral reaction and is that the intent?  These are the kind of questions that run through my mind when I hear someone say this, and I think perhaps these are the questions that any person making this statement needs to consider.

I know that some student anesthesia nurses might feel somewhat slighted at this kind of mention of monkeys and intubation, especially if it’s an anesthesiologist talking.  But I assure you that anesthesia residents and medical students hear this phrase directed at them just as often if not more. It’s not until you’ve become comfortable and routinely successful at intubating patients that this perennially repeated phrase starts to make sense.  Call it a difference of perspective, but once you get that intubating monkey off your back, this phrase that seemingly belittles the beginning student starts to take on a different meaning.

Of course, we anesthesia folks don’t have a monopoly on the phrase.  In fact people in the EMT and paramedic world seem to use it a lot more.  In many locales, intubation of patients in the field forms a big part of the contentious division between EMTs and paramedics in terms of who is allowed or not allowed do it.  But it’s interesting…in the paramedical field, when someone says “whatever…you could teach a monkey to intubate!“, they are usually trying to downplay the difficulty or importance or mystique of intubating in order to get more privilege, right?

So why is there a difference in why this phrase is used and how this phrase is perceived?  For anesthesia folks, the phrase is almost denigrating, implying that just because you can intubate doesn’t mean that you can do everything an anesthesiologist or CRNA does.  And for the paramedical crowd, it implies that intubation is such a basic skill that anyone should be allowed to do it.  Who is right?  As usual, the devil is in the details and some color can be found in the following studies:

• Prehospital Oral Endotracheal Intubation by Rural Basic Emergency Medical Technicians
• Field Trial of Endotracheal Intubation by Basic EMTs
• Misplaced endotracheal tubes by paramedics in an urban emergency medical services system

Just to give you the lay of the land, EMTs are generally the ones who are saying that “even monkeys can be taught to intubate” as the procedure is usually limited to paramedics who have more extensive training.  But as these studies show, EMTs who work in areas where regulations allow them to intubate in the field aren’t really that successful in doing so.  Their chances of successful intubation hover right around 50:50.  Paramedics love to point to the EMT studies as evidence that EMTs should not be allowed to perform the hallowed practice of intubation, but their own best numbers still allow for upwards of a 25% failed intubation rate with the tip of the tube most often being found either in the esophagus (67%) or in the hypopharynx (33%).  These aren’t just failed intubations…these are UNRECOGNIZED failed intubations.  Of note, over half of the unrecognized esophageal intubation patients died and a full third of the patients died with the tip of the tube in their hypopharyx.  Of course we don’t know what the ultimate cause of death in these cases was, but let’s face it:  a 75% rate of successful intubation coupled with a 25% rate of unrecognized failure of proper intubation just ain’t gonna cut it.  But is it better than nothing?

• Complications and failure of airway management

In contrast, for anesthesia practitioners, rates of failed intubation are quoted to be ~1 in 1-2000 for elective intubations, ~1 in 300 for RSIs in the OB population, and ~1 in 50-100 in out-of-OR situations such as in the ED, ICU, and other pre-hospital arenas.  These numbers do not describe the circumstance of truly unrecognized failed intubation (usually esophageal intubation) because this number approaches 0% for anesthesia practitioners, although the absolute number is greater than zero in the closed claims project database.  These are the kind of numbers that we expect as anesthesia folks: virtually 100% success and 0% failure with 100% recognition of failure.  And that’s why when one of us says “I could teach a monkey to intubate” it is generally meant and taken as a negative comment to obviate the skill of intubation…not as an achievement, but as a minimum requirement.

Being able to successfully intubate 50% or 75% or even 95% of the time is still an overall failure, especially when the failed intubations go unrecognized as in the EMT/paramedic studies.  The argument here is that partial success at intubating is still better than no intubation capability at all.  But it’s obvious that unrecognized failed intubation by itself, which occurred in upwards of 25% of paramedic intubations and over 50% of EMT intubations, leads to death in and of itself.  Nevermind the reality that many of these patients may not have required intubation in the first place.

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So after all this talk about intubating success and failure, why are we so fixated on it?  As students and residents, why is getting your first intubation such a transformative experience?  Why is the very act of intubation put on such a high pedestal?  And why is the self-worth of every student and resident measured by their intubation success-to-failure ratio?  I think it’s because it is one of the only visible or tangible things that people identify with the field of anesthesia.  A large majority of our practice is based on a gestalt of an infinite number of variables that we observe, and yet getting the tube into the trachea is a very binary event…it’s either in or not…with very satisfying indicators of success:  end-tidal CO2, chest rise, rising SpO2.

But is intubation really ever that important or vital?  Should it be a skill that defines us as anesthesiologists and CRNAs?  Or is it simply a very basic skill that anyone – perhaps even a monkey – should be able to learn and perform flawlessly?  Even though there will always be people that are better at it than others, intubation is a skill.  And like any skill, practice makes perfect…continuous, daily, repetitive practice.  But a more important and more difficult skill to master than intubation is bag-valve-mask (BVM) ventilation.  It’s not sexy and it doesn’t protect the airway from aspiration, but being able to deliver adequate positive pressure breaths via BVM ventilation will save more lives time and time again compared with intubation.  And last I checked, there are no arbitrary rules or imaginary lines of hierarchy dictating who can and cannot provide BVM ventilation.  Yet it’s very rare to see anyone outside of anesthesia personnel with good BVM ventilation skills…In every multidisciplinary critical events simulation or ACLS megacode I have attended, everyone always reaches for the laryngoscope to intubate when it’s their turn to be at the head of the bed.  Shrug.

Intubation is dangerous.  Everything associated with it – the laryngoscope, the tube, the stylet – they are all weapons and can be used to injure and kill the patient they are used on.  And I’m not just talking about the necessity of using the laryngoscope properly or passing the tube gently or removing the stylet before it causes tracheal injury.  The very act of intubating is just that. But more critical is making sure that criteria for intubation are met – that the patient needs to be intubated – or anticipating that a patient has a difficult airway…can the patient be intubated.  And more important than getting the tube in is being able to recognize unsuccessful intubation immediately and knowing how to proceed from there.  You see, it doesn’t matter how good you are at actually getting the tube in…it’s what you consider before deciding that a patient needs to be intubated and how you manage a patient after you’ve intubated them, or tried and failed, or decided that they don’t need intubation at all.  The old adage that “everything looks like a nail when all you’ve got is a hammer” comes to mind for the people that would teach monkeys to intubate.

“Patients don’t die because we can’t intubate them, they die because we can’t stop trying.”

Even the most current ACLS guidelines have started to de-emphasize the role of early advanced airway placement and re-prioritize chest compressions, early rhythm analysis, and immediate defibrillation if warranted.  Much of this move stems from the recognition that intubation is a specialized skill that few people outside of an anesthesia department can perform with anything close to 100% success.  At a minimum, precious time-to-defibrillation is wasted trying to intubate.  But the AHA also recognizes that real harm can be done by encouraging non-anesthesia providers to attempt intubation when rescue breathing by mouth-to-mouth or BVM ventilation would do just as well if not better in most circumstances.  Esophageal intubation leading to aspiration, multiple attempts leading to airway bleeding or swelling and eventual loss of patency, etc. all come to mind.

The bottom line is that you can’t simply teach monkeys to intubate – or – you wouldn’t want to even if you could.  We use the monkey metaphor and it’s negative connotation to remind students and residents  that intubation is a skill that holds little value by itself, and yet, it’s a skill that must be mastered to as close to 100% proficiency as possible.  It’s a tool to free up our hands and protect the airway from aspiration and not a means to an end in terms of curing a patient.

Excerpted from:  Endotracheal intubation: friend or foe, 1986

“In other words, you very well might be able to teach a monkey to intubate, but can you teach a monkey NOT to intubate?”

So that’s my reflection on our practice of anesthesia for today.  I know it’s convoluted and random and mostly worthless drivel, but it’s what occurs to me when I have long days in the OR spent sitting behind the drapes.  Maybe it strikes a chord with you, maybe it doesn’t.  But thanks for reading.