College Answer

The answers provided by the candidates were very disappointing. Endotracheal intubation is so fundamental to Intensive Care practice that a high standard was expected in this question to obtain a pass mark. A list of the major complications and some suggestions regarding prevention were required. Very few candidates included myocardial ischemia, elevation of ICP, the potential for spinal cord injury in the presence of an unstable spine, or even failed intubation. Few candidates listed pre-oxygenation as potentially helpful in preventing hypoxia.

Potential adverse effects included:

Hypoxia, Failed intubation, Oesophageal intubation, Endobronchial intubation, Aspiration, Bronchospasm, Structural damage (including Cord injury/False passage), Foreign body aspiration, Bacteraemia, Hypertension/tachycardia/arrhythmias/myocardial ischaemia, Raised ICP, Hypotension/exacerbation of shock state, Other drug side-effects, Sputum retention / pneumonia, Sub-glottic stenosis, Tracheo-oesophageal fistula.

Discussion

The candidate, who is preparing for their fellowship, does not need to hear how disappointing the college finds the previous candidates. Even among the genre of college feedback, which is notoriously unhelpful, such comments are especially pointless. Must we open a window on this? Sure, not one of the candidates achieved the "high standard" which the examiners considered a pass mark. But some might say that the candidates, all being senior ICU staff, by definition have a superlative understanding of intubation, and that the question was worded in such a profoundly stupid manner that this knowledge did not have a chance to spill out onto the answer booklet. 

Perhaps one might have asked:

"What are the acute physiological consequences of a successful endotracheal intubation? How might these impact adversely on the critically ill patient?

What might be the adverse consequences of a failed intubation attempt?

"Describe some steps which might be taken to protect the patient from these consequences."

"You may tabulate your answer."