How to intubate: Teaching a medical student during anesthesia residency

The first time I let a medical student try to intubate was in August. Now in my final year of anesthesia residency, I had volunteered to mentor a third-year medical student for a week. A few weeks in advance I got an email with the form she had filled out. Anesthesia experience: none. Excited to learn: yes.

I met her on Monday morning after she navigated through the preoperative holding area to our patient’s bedside. Every day she took out her sheets of paper with the checklist for the one-week medical student anesthesia rotation, and I dutifully initialed each of the topics that we had covered. What are the critical parts of the preoperative anesthesia evaluation? What is the Mallampati airway classification system? Name four induction medications and their important differences. What are the risks of placing a central venous catheter?

Each day we met at 6:30 and I tried to give a quick rundown of the day’s cases. I had just entered the final year of my residency, so the cases were big, the patients were sick, and I often had a new first-year resident paired with me, so the opportunities for her to try procedures were few. A partial liver resection. A splenic tumor debulking with lung isolation. Sorry, I would say, but we need a really big IV for this one and her veins are just awful. I would love to let you try to intubate but there is a conduit between the tumor and his stomach so we really need to get it in on the first try.

Three days later she had checked off most of the discussion topics on her list but I felt so guilty every time she doggedly followed me to meet a new patient in preop holding, her size small scrubs hanging off her tiny frame, cuffs dragging on the floor. This one already has an IV and needs a thoracic epidural, sorry. Sorry but our attending is particularly impatient and I only have a second to get a 16-gauge IV in this guy’s hand before we flip him onto his belly and he weighs 350 pounds and is currently having a junctional bradycardia with a heart rate of 30. I actually need to do this IV because we have to connect this special rapid-transfusion machine to it because there is just a lot of blood flow to the liver, sorry. A rapid-sequence intubation is what we do when a patient has a high risk of vomiting and then aspirating gastric fluid during intubation, and when we’re worried about that it’s probably not the best circumstance to try intubating for the first time.

I felt like a complete failure at the medical student mentoring thing. I have always loved teaching. I have no formal training, and I’ve never thought I was particularly good at it, but I got the resident teaching award from the medical students during internship and it really made me hope that I deserved it and want to try harder. So when I got the email from the anesthesia department looking for volunteers, I signed up immediately. I am married to a gifted teacher so I asked him for suggestions, looked over the questionnaire she filled out and reviewed the checklist of discussion topics to make sure I knew the answers.

We had had plenty of time to cover the discussion topics. We would talk over coffee during my morning break. We spent hours sitting on chairs in the back corner of the operating room going down the list while the junior resident assigned to the case managed the details when the patient was stable. I did finally manage to get her an IV to put in. The patient was asleep, the vein was huge and the pressure was off. She popped through the skin and then dropped her angle. After she saw the flash of blood she advanced a tiny bit more, remembering how the bevel needs to get all the way into the vein, and then slid the plastic catheter off.

“Perfect. It runs like a hose!”

But what I remember most from my anesthesia rotation in medical school, what was so incredibly exciting and daunting and perfect, was intubating someone for the first time. It was June of my third year, and I got off the waiting list for the anesthesia elective at the last minute. I had a few weeks free and I had heard everyone was nice and you get out early and you learn how to intubate and put IVs in. Every day they let me go from room to room, doing a slew of intubations in a row.

“Nice job on the intubation. Now why don’t you go intubate next door and then come back and I’ll see what other procedures I can find for you?” I was in heaven. I fell in love.

But it was Thursday afternoon, and I was on call that night and going on vacation the next day. I had found another senior resident to work with her on Friday, but this was it. Four days and she had put in one IV and had not managed a single airway. I felt awful. And then our last patient of the day showed up in preop holding. She was fasted. She never got heartburn. She was hemodynamically stable. When she opened her mouth, I could clearly see the tip of her uvula and the entirety of her posterior oropharynx. The distance was ample between the tip of her chin and the thyroid cartilage in her neck. Her head rotated smoothly down and up on its atlantooccipital joint. She had no teeth. Her airway was perfect. I paged my medical student back from the case I had dispatched her to. “I found an intubation for you!”

We went over the plan. If you can ventilate easily, we will do everything smoothly and slowly. Show me how you’re going to hold the blade. Walk me through what you should see when you are past the base of the tongue. As long as you tell me what you are seeing and what you are doing at each step I will let you manage her airway entirely. I cleared the plan with the junior resident on the case, who herself had done only a few dozen intubations but was confident with ones as easy as we predicted this to be. I was thrilled.

An entourage of anesthesia personnel wheeled our patient back to the operating room. Our attending, a confident and calm woman who agreed with my plan, watched the scene unfold calmly from her perch against the side wall of the operating room. The junior resident attached all the monitors. I grabbed the syringes of medications that I usually hand to my attending. It was my turn now to stand by the patient’s arm and push the medications into the IV. The junior resident stepped aside from the head of the bed and my medical student took the oxygen mask.

First I flushed propofol into the IV.

“Do you think she’s asleep?” I asked.

“Can you open your eyes?” She brushed her lashes gently to check.

“Give a breath.” With the oxygen mask clutched tightly in her tiny left hand, she squeezed the bag with her right. Nothing. I let her struggle for a few seconds.

“I don’t see any carbon dioxide coming back, so try closing the pop-off valve so you have more pressure to ventilate her with.”


“I still don’t see any carbon dioxide coming back, so try an oral airway – she doesn’t have any teeth so there is really nothing stenting her mouth open.”

“Good, you’re ventilating! Now I’m going to give the paralytic, which will take three minutes to kick in, so turn the sevoflurane on to keep her asleep and keep ventilating. I’ll watch the clock.”

Three minutes is a long time to mask-ventilate someone when you’ve never done it before. Her hand got tired but she did not complain.

“Why don’t you take a look.”

She hands the oxygen mask to the nurse, picks up the steel laryngoscope and snaps the blade open. Just as we talked about, she inserts her right thumb and index finger into the patient’s mouth and scissors her jaw open to make room. With her left hand, she inserts the laryngoscope blade, shining steel and as long as her hand, into the right side of the mouth. Awkwardly, slowly, she works her way in.

“I don’t see anything.”

“Keep going in deeper.”

“I think I see the base of the tongue still.”

“Keep going deeper. As long as you are being gentle you’re not going to hurt anything.”

“I see epiglottis.”


“I see the vocal cords.”

“Are you sure?”


The nurse places the styletted endotracheal tube into her right hand and she pushes it in. The nurse takes the stylet out, she advances further and attaches the endotracheal tube to the anesthesia machine. The nurse inflates the cuff that seals the patient’s lungs off from her stomach. She gives a breath.

No chest rise, no carbon dioxide. She put it in the esophagus.

“Now deflate the cuff and take the tube out. Put the oxygen mask back on and keep ventilating. Remember, she is asleep and we are breathing for her. She is fine.” I have the junior resident step in and intubate, which she does with ease. I am getting sweaty but she looks to me to see if I am calm, if everything is still okay.

“Great job! Good job ventilating, it can be really difficult in a patient with no teeth. You did a great job scissoring the mouth open and your grip on the laryngoscope blade was perfect. I like how you went in slowly – if you can ventilate there is never a reason to rush. Excellent technique for your first intubation.”

And putting the tube in the esophagus – everybody does that the first time.

Felicity Billings is an anesthesiology resident who blogs at One Case at a Time.

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