# VL exclusively



## NomadicMedic (Apr 19, 2018)

Does your service mandate video laryngoscopy? If so, how did you make the change? What drove the change? How did the medics react? Did your first pass success rate improve? What VL are you using? 

Can you tell I want to know everything?


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## Colt45 (Apr 19, 2018)

We have king vision, and it's  at the discretion of the medic to use it, or just stick with DL. Personally in intense situations I will use DL and a bougie. I could care less about the "status". I need to take an airway and I get it first time. First time pass attempts are much higher with VL where I'm at. But some of the old school medics cry about it and laugh when you use it. I've done plenty of DL especially through my OR clinical locations. I'm not to worried about impressing anyone.


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## StCEMT (Apr 19, 2018)

It isn't mandated, simply provider choice. We carry McGrath's on the supervisor trucks and they respond to all cardiac/respiratory arrests and other such calls. The McGrath is frequently used though, the last few intubations I've had supervisors do have all been done with a McGrath. Purely anecdotal, but it seems like our supervisors tend to go for the McGrath first and field medics DL first. That may also be due to the fact that those intubations were all on scene without the luxury of perfect space and positioning.

I don't use the McGrath as my first line. I typically go Mac/Miller 3--->McGrath--->King. My reason is simply to keep some familiarity with DL in the event that VL isn't an option. That being said, I keep the time I will look fairly short before resorting to the next steps in my plan and usually do have an easier time getting a good view with VL.

What is mandated is that we use a bougie on all intubations. I prefer preloading mine and use the method the CRNA Bonjo Batoon made a video showing. It's proven to be a stable way to preload and easy to manipulate.

I don't know what the success rates are between DL vs VL. I tend to have an easier time using VL and I imagine that is pretty universal, but I can't speak to the exact numbers. I would say what has helped me the most isn't the laryngoscope (not that it hasn't been beneficial as well), but positioning and padding. The majority of our intubations are done during cardiac arrests and the autopulse will rock that head all over the place. Stuffing a bunch of blankets gives a stable platform and view. That and ramping the head up a little bit to change my angle have proven to be the biggest help since I've worked here.

I think one thing that doesn't get enough attention is the prep work BEFORE an intubation that makes it successful. I wouldn't be opposed to VL being mandated, but I do think that more emphasis needs to be placed on what we do before we even touch the laryngoscope.


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## CALEMT (Apr 19, 2018)

VL hasn't made its way to our corner of the world. A buddy of mine who is doing his internship in a neighboring divisions told me that the FD is going through a "trial" period with VL. Don't know the brand, but my buddy said that got the tube on a full arrest. Based on how he described it and what he's seen with his interactions with it, it sounds just as good if not better than DL. Me personally if given the option of VL or DL I would be going for the Mac 3 or 4 first, just to keep those skills relatively fresh. Yeah VL is extremely helpful and all, but technology fails and as everyone knows in the moment where you need a tube it ain't going to be working. 

As StCEMT has said, prep work is everything. I find taking the extra couple of seconds to ensure the pt is properly positioned and padded makes life easier. It will be interesting to see if we get VL in the future. I personally would like to see it.


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## TXmed (Apr 20, 2018)

VL and bougie mandatory with our VL being mcgrath. Im fine with it being mandatory as i use the mcgrath DL anyways and just use the video for a reference if i need to. Our FPS is about 95%+ which is good i think considering we get all the hard airways because if they were perceived to be easy the ground would have done them PTA. 

The king vision is popular down here and my opinion of it is not good. Ive come up on so many airways where the medic is pounding away at it.

As the ones above me had said the prep work is what really makes a difference. I still undo the c-collar, ramp, ear to sternal notch and suction every patient. 

Rebel EM just reviewed a study about bougie FPS with cmac.


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## Carlos Danger (Apr 20, 2018)

Just like ultrasound for line and nerve block placements took a while but is now unquestionably considered the standard of care, I'm pretty confident there will be a time not too long from now when VL is considered the standard of care.

There's quite a bit of research on VL vs. DL in the ED setting, with all of the studies showing anywhere from no advantage to a significant advantage (and most showing at least some advantage) with VL, and none that I know of that show VL as inferior to DL. The advantages of using VL will increase as the devices become better and more affordable, which is already happening compared to the first generations of them.


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## DrParasite (Apr 20, 2018)

Quite simply, we don't have them on every truck when I was still working EMS.  IIRC, out of 9 trucks in the system, we purchased two, and they were given to the two supervisors (who responded on all cardiac arrests, but never beat the ambulance to the scene).  So their real world use was pretty limited.

They look awesome, they are expensive, and they are new to EMS. And it should increase success rates. 

But like many things in EMS, the old school will push back "we didn't need those fancy things to intubate back in the day," the new school will like them but not want to be seen as requiring a crutch to do the job (at least that is what they will hear from their FTOs), and if they aren't maintained by administration, and technologically updated as needed, the field personnel's view of them will not be positive.


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## NomadicMedic (Apr 20, 2018)

DrParasite said:


> Quite simply, we don't have them on every truck when I was still working EMS.  IIRC, out of 9 trucks in the system, we purchased two, and they were given to the two supervisors (who responded on all cardiac arrests, but never beat the ambulance to the scene).  So their real world use was pretty limited.
> 
> They look awesome, they are expensive, and they are new to EMS. And it should increase success rates.
> 
> But like many things in EMS, the old school will push back "we didn't need those fancy things to intubate back in the day," the new school will like them but not want to be seen as requiring a crutch to do the job (at least that is what they will hear from their FTOs), and if they aren't maintained by administration, and technologically updated as needed, the field personnel's view of them will not be positive.




FWIW, we have a KingVision on every truck. The use was mandatory and has fallen by the wayside through attrition. 
I'm working on rebuilding the clinical competency here...


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## DrParasite (Apr 20, 2018)

NomadicMedic said:


> FWIW, we have a KingVision on every truck. The use was mandatory and has fallen by the wayside through attrition.
> I'm working on rebuilding the clinical competency here...


Might be a little off topic, but you are describing two different issues: 1) the KingVision is mandatory, and (for whatever reason) staff aren't using them and 2) clinical competency (which I am assuming means people aren't intubating successfully on the first attempt).  

1) if the rules say you must do this, and they aren't do this, than progressive discipline should occur.  They know the rules, they decided to ignore the rules, there are consequences.  if you want to make the VL optional, paramedic discretion, another tool in the box etc, (which is why I encourage) do so.  But if its mandatory, they SHALL use it every time, and they aren't, than you need to do something to correct that behavior.

2) if your clinical competency has decreased, and one factor you have noticed is many of the failed attempts did not use the VL, have an QA meeting with the involved paramedics.  The reason: failed to secure airway.  secondary reason: failed to utilize all the available tools provided by the agency in order to attain the goals.  If they can do it with DL, awesome, you are trusting your paramedics judgement in what they feel comfortable using (we have the same arguments for ETT vs Kingtube on cardiac arrests).  But if they are unable to do the DL, and for some reason are still resistant to using the VL, than that requires either re-education or counseling on what is best for the patients.


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## Tigger (Apr 20, 2018)

KingVision is mandatory at AMR here. We still carry DL equipment but it is not to be used as a first attempt unless there is some untoward situation which has yet to apparently occur. The old DL success rate was 60%, with the advent of the KingVision success rates stayed the same and then actually dropped. Turns out you have to train people when new equipment is implemented, once that happened the success rate climbed to around 90%. I am not sure what the first pass success rate is.

My fulltime job has McGraths on every ambulance. It's provider choice on whether you want to use it or not. Every medic but one does, he is of course my captain.


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## VFlutter (Apr 20, 2018)

We have a choice but VL is strongly encouraged for most situations. We use the C-Mac and many providers will do traditional DL at first and only look up at the monitor if needed. I think its a huge benefit to have a traditional blade as opposed to proprietary or hyperangulated blade like some VL so you can transition VL -> DL if needed. Our company wide first pass success rate is very good (~93%, n~1,000) even with many novice intubators (RNs).


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## VentMonkey (Apr 20, 2018)

Only my division (CCT) has VL capabilities. I wish it was mandated across the board for all ground crews, and perhaps even CCT crews. If my patient even looks so much to be a troublesome airway, protocol or not, I’m going straight to VL—>King Airway.

My personal opinion is that—given our infrequency with ETI—it should do away with DL in the prehospital setting altogether. As it is we struggle with what’s given now, and all most (piss poor) paramedics do is piss and moan about losing this “crucial life-saving skill” (insert gag).

I do agree with doing away with hyper-angulated VL blades/ models, but as of now, the first generation models are somewhat in their “trial phase”. Dr. Kovacs has a pretty good tutorial on the two different models.

Again, given the haphazard job that we (collectively) do in the field we don’t necessarily need DL if VL is constantly proving its superiority; then again, I’m content with an RSA being standard in the out-of-hospital setting.


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## RocketMedic (Apr 20, 2018)

Kingvision VL is the de facto default at Creek, with both styles of blade _and_ the CoPilot rigid stylette, or bougie. I like the idea, but I don't think that the Kingvision is a particularly fantastic bit of gear. It works, but I would prefer a McGrath or CMAC. 

I really, really would like to carry Igels and McGraths.


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## Carlos Danger (Apr 20, 2018)

RocketMedic said:


> Kingvision VL is the de facto default at Creek, with both styles of blade _and_ the CoPilot rigid stylette, or bougie. I like the idea, but I don't think that the Kingvision is a particularly fantastic bit of gear. It works, but I would prefer a McGrath or CMAC.
> 
> I really, really would like to carry Igels and McGraths.



CMAC and igel is pretty much all anyone ever needs. Really great pieces of equipment.


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## StCEMT (Apr 21, 2018)

Remi said:


> CMAC and igel is pretty much all anyone ever needs. Really great pieces of equipment.


While my experience is purely with a McGrath, if I had to choose any two airway devices it would be these. I miss the igel, that was my favorite of all the SGA's.


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## aquabear (Apr 22, 2018)

So I’ll start with this.

http://www.wilco.org/Portals/0/Departments/EMS/King Vision Intubation.pdf

We made the change based on data. Our Medical Director looked at our FPS rate with DL and wasn’t happy and so we switched to VL and conducted that study.

We now exclusively intubate using King Vision (with a #3 channeled blade) since the conclusion of this study. The only DL we do is intubation/airway suctioning for meconium aspiration and removal of FBAOs when the King Vision won’t fit. We went from a 40-50% FPS with DL to a routinely having over a 90% FPS rate with VL.

That high FPS rate is a combination of detailed training in our New Hire Academy where you learn how to use the King Vision “the Wilco Way,” learning SALAD with dummy training, monthly training/skill sign offs with a Senior Medical Officer and a robust QA process for each intubation attempt.

My personal views here, King Vision is a great product, but I wish it had more features like video recording as it would aid in training and QA.


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## NomadicMedic (Apr 22, 2018)

Good stuff. The reason I asked was because I want to move our service to the WilCo method of intubation. I may reach out to Dr Jarvis and see if I can take a WilCo airway class and bring the method back home.


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## TXmed (Apr 22, 2018)

NomadicMedic said:


> Good stuff. The reason I asked was because I want to move our service to the WilCo method of intubation. I may reach out to Dr Jarvis and see if I can take a WilCo airway class and bring the method back home.



There is a youtube video entitled intubating the Williamson county way or something like that. Its pretty good, you should watch it. Im a big believer in standardizing airway protocols and procedures. When i was a wee little medic i remember the all the veterans had their own way of doing everything "well i like to do it like this blah blah blah" in reality there shouldn't be any specific way. There should be what works IE: bougie everytime, 2-hand seal everytime, peep valve everytime, head in ear-sternal notch everytime etc. and while i mayyyyy disagree with some of the things Dr. Jarvis says/does i do respect him for going in a standardizing such an important aspect of our profession. And then proving that it works.


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## StCEMT (Apr 23, 2018)

NomadicMedic said:


> Good stuff. The reason I asked was because I want to move our service to the WilCo method of intubation. I may reach out to Dr Jarvis and see if I can take a WilCo airway class and bring the method back home.


Are all your trucks (or will they be) outfitted with video laryngoscopes or is that only on supervisor trucks?


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## NomadicMedic (Apr 23, 2018)

We have a KingVision in every set of ALS gear.


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## DrParasite (Apr 23, 2018)

If it's on every set of ALS gear, why do paramedics are your agency not like using it?


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## FiremanMike (Apr 23, 2018)

Remi said:


> Just like ultrasound for line and nerve block placements took a while but is now unquestionably considered the standard of care, I'm pretty confident there will be a time not too long from now when VL is considered the standard of care.
> 
> There's quite a bit of research on VL vs. DL in the ED setting, with all of the studies showing anywhere from no advantage to a significant advantage (and most showing at least some advantage) with VL, and none that I know of that show VL as inferior to DL. The advantages of using VL will increase as the devices become better and more affordable, which is already happening compared to the first generations of them.



The biggest issue I see with VL in the ED is that they generally go with the glide scope and I swear it seems like they just toss those things at residents and say "use this, you'll figure it out".  Glide-scopes work well if you know the technique, but they work terribly if you don't, and it's usually pretty obvious whether or not the person you're watching has been appropriately trained on the technique or not. 

My exposure to this only ever comes in the ED, I'm sure you've seen this behavior throughout the hospital.

I have to wonder if these scenarios aren't skewing the data.


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## NomadicMedic (Apr 23, 2018)

DrParasite said:


> If it's on every set of ALS gear, why do paramedics are your agency not like using it?



Not sure. I think part of it is “Paramedics intubate with a real laryngoscope” bravado.

Some of the guys have poor technique and that  lead to “it must be this #%^ video POS”


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## VentMonkey (Apr 23, 2018)

NomadicMedic said:


> Not sure. I think part of it is “Paramedics intubate with a real laryngoscope” bravado.
> 
> Some of the guys have poor technique and that  lead to “it must be this #%^ video POS”


Going out on a limb here and gonna say this is yet another s/s of paragoditis. I’m also willing to bet that this is hardly an isolated regional mindset. 

If we have paramedics who still chastise Bougies and see them as a crutch, I can’t imagine how “weak” they feel having to learn VL. 

All in all, we don’t deserve a lot of the skills we’re afforded, at least not until the national model is restructured.


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## StCEMT (Apr 23, 2018)

VentMonkey said:


> All in all, we don’t deserve a lot of the skills we’re afforded, at least not until the national model is restructured.


Unfortunately I think the only way anything will change any time soon is individual initiative within departments to implement their own changes.


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## NPO (Apr 24, 2018)

NomadicMedic said:


> Does your service mandate video laryngoscopy? If so, how did you make the change? What drove the change? How did the medics react? Did your first pass success rate improve? What VL are you using?
> 
> Can you tell I want to know everything?


I'm in Southwest Missouri where everything varies by agency as there is little state oversight.

At my agency we have KingVisions on every truck and are required by policy to attempt VL prior to manual laragoscopy. That policy is loose however, for example KingVision doesn't have pediatric sizes, in cases of FBAO, etc...


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## DrParasite (Apr 24, 2018)

NomadicMedic said:


> Not sure. I think part of it is “Paramedics intubate with a real laryngoscope” bravado.
> 
> Some of the guys have poor technique and that  lead to “it must be this #%^ video POS”


That's kind of where I was getting at.... Have you, ummm, asked them?  You are now a white shirt, what's stopping you from pulling someone into your office and saying "you missed the tube on the first attempt, why did you not use the VL, which is exactly what policy requires that you do?"  They might say something else like "the VL picture sucks, I can't see as clearly, the batteries are always dead, the thing is too heavy, etc."  I don't know, but instead of guessing, does it hurt to ask everyone one on one, especially after a failed airway attempt?

I mean, if they can tube without the VL, than you can trust them to use their judgement, however if they are failing (for whatever reason, poor technique, not using the VL, not using the bougie, etc), than corrective action should be taken.


VentMonkey said:


> If we have paramedics who still chastise Bougies and see them as a crutch, I can’t imagine how “weak” they feel having to learn VL.


I've heard of this.... my former medical director also told every one he didn't care if they used a bougie every time, whatever tools that he approved you need to do the job, use them!!!

I had a paramedic FTO who refused to touch a SGA on a cardiac arrest.... if he needed an airway, he was using an ETT.  a SGA was only in case he was able to use the ETT after multiple attempts.


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## Bullets (Apr 25, 2018)

We are rolling out Airtraqs to all ALS units May 1. We will see how it goes.


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## NomadicMedic (Apr 26, 2018)

Bullets said:


> We are rolling out Airtraqs to all ALS units May 1. We will see how it goes.



I like the new airtraq. It’s pretty nice.


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## E tank (Apr 27, 2018)

VentMonkey said:


> Going out on a limb here and gonna say this is yet another s/s of paragoditis. I’m also willing to bet that this is hardly an isolated regional mindset.
> 
> If we have paramedics who still chastise Bougies and see them as a crutch, I can’t imagine how “weak” they feel having to learn VL.



Those medics would be laughed out of every anesthesia lounge in the country.


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## TXmed (Apr 27, 2018)

E tank said:


> Those medics would be laughed out of every anesthesia lounge in the country.



Because of bougie use or VL use?


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## E tank (Apr 27, 2018)

TXmed said:


> Because of bougie use or VL use?



No, sorry for being so unclear...for disparaging the use of those things.


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## VentMonkey (Apr 27, 2018)

E tank said:


> Those medics would be laughed out of every anesthesia lounge in the country.





E tank said:


> No, sorry for being so unclear...for disparaging the use of those things.


Sadly, our profession seems to work in opposition of this mindset, hence my remark:


VentMonkey said:


> *All in all, we don’t deserve a lot of the skills we’re afforded, at least not until the national model is restructured*.


Nothing like being the outlier, eh?...


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## E tank (Apr 27, 2018)

VentMonkey said:


> Sadly, our profession seems to work in opposition of this mindset, hence my remark:
> 
> Nothing like being the outlier, eh?...



Well, don't be too hard on yourself. A lot of that mindset comes from immaturity and inexperience, not from a lack of merit on the part of some folks where those skills are seen as necessary for a given region. 

The fact is that there just won't be the opportunity to become a true expert at things like DL/intubation even in most metro areas. Intubating 3 times a month is just enough to reinforce bad habits, not get better. This has nothing to do with merit on the part of the medics. Pure numbers, that's all.


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## MSDeltaFlt (Apr 28, 2018)

I am an old school respiratory therapist and an old school paramedic.  And I'm all for technology.  Technology is great and getting better.  But if and when technology fails (and it does and will), there is no school like the old school.  But with old school technique is everything.  Which, in my honest opinion, tends to be lost on more medics than they might be willing to admit.

My current service doesn't stress technique.  My last air service I was with stressed technique... a lot.  My air service before that one?  Not as much.

Just my humble $0.02.


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## E tank (Apr 28, 2018)

MSDeltaFlt said:


> I am an old school respiratory therapist and an old school paramedic.  And I'm all for technology.  Technology is great and getting better.  But if and when technology fails (and it does and will), there is no school like the old school.  But with old school technique is everything.  Which, in my honest opinion, tends to be lost on more medics than they might be willing to admit.



"Old school" was once cutting edge technology. And people got F'd up. Until "new school" came along. Pulse ox, ETCO2, heck, Miller blades. Ever even seen a Wis-Hipple blade? Google it and just imagine intubating a huge necked, short jawed, small mouthed dude with garbage in his airway. You're right about technique tho, Bro. But killing a lion with a rifle is way better than doing the same thing with a rock.


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## MSDeltaFlt (Apr 28, 2018)

E tank said:


> "Old school" was once cutting edge technology. And people got F'd up. Until "new school" came along. Pulse ox, ETCO2, heck, Miller blades. Ever even seen a Wis-Hipple blade? Google it and just imagine intubating a huge necked, short jawed, small mouthed dude with garbage in his airway. You're right about technique tho, Bro. But killing a lion with a rifle is way better than doing the same thing with a rock.



"Those who cannot remember the past are condemned to repeat it." - George Santayana (1863-1952), Reason in Common Sense, The Life of Reason, Vol.1

This can easily be applied to EMS.  Specifically regarding one's training.  BLS before ALS.  My grandmamma used to always tell me, "Remember who are and where you come from".  Wise woman.  I use that a lot and it hasn't failed me yet.  I highly doubt that it ever will.

Remember your training.  Remember your technique.  Don't be the one who forgets what they were before they were trained and began performing like they did before they were trained as I am referencing the above quote.

I think I mentioned something in my previous post I believe it was sentence number 2 that I am all for technology.  These new toys are great and cool.  And significantly increase first time pass rates.  But technology fails.  Everything that has been made has broken.  EVERYTHING.  

So when will your new fangled whatchamacallit break on you?  When your patient can least afford it to break.  Technology fails.  Technique won't.  Use technology.  I know I will.  But when it fails do your patient a huge favor and make d@mn sure your technique doesn't.


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## VentMonkey (Apr 28, 2018)

I hope and pray for the day that RSA is the standard. Given the new “technology” of LMA’s, and other EGD’s/ SGA’s it makes total and complete sense that it should go this way.

Also, I fail to see the relevance in your point. Batteries fail with DL laryngoscopes as well.

Again, wouldn’t patients in the prehospital setting be better served with less bravado, and more simplistically-driven quality care? Or are we truly that lost in our own egos? I know what my personal opinions and answers are, what say you all?


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## MSDeltaFlt (Apr 28, 2018)

Wow.  So many appear to be very eager to forego the history of technique of airway management.  Well, good luck with that.  Just be sure and remember one thing.  You're to raise your right hand, not your left, when you swear of affirm that the testimony will give with be the truth, the whole truth, and nothing but the truth so help you God.


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## StCEMT (Apr 29, 2018)

Where do you see anyone advocating throwing technique aside? Did you miss the part where a few of us mentioned the importance of preparation and positioning? Or watch the video of the method Nomad is interested? Doctor Jarvis goes over technique in detail. So I don't see where you think anyone is saying to throw technique in any sense aside....


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## Tigger (Apr 29, 2018)

MSDeltaFlt said:


> "Those who cannot remember the past are condemned to repeat it." - George Santayana (1863-1952), Reason in Common Sense, The Life of Reason, Vol.1
> 
> This can easily be applied to EMS.  Specifically regarding one's training.  *BLS before ALS.*  My grandmamma used to always tell me, "Remember who are and where you come from".  Wise woman.  I use that a lot and it hasn't failed me yet.  I highly doubt that it ever will.



That phrase needs to die. The right intervention at the right time is what matters.


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## TXmed (Apr 29, 2018)

Tigger said:


> That phrase needs to die. The right intervention at the right time is what matters.



Fully agree


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## E tank (Apr 29, 2018)

MSDeltaFlt said:


> So when will your new fangled whatchamacallit break on you?  When your patient can least afford it to break.  Technology fails.  Technique won't.  Use technology.  I know I will.  But when it fails do your patient a huge favor and make d@mn sure your technique doesn't.



What technique do you use when your ambulance won't start?


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## VentMonkey (Apr 29, 2018)

I didn't understand the remark either. Without carrying this thread completely off of the rails I will add, most of my mentors have been and are older than I. The one thing none of them do is pigeon-hole themselves with labels. They, much like myself, are truly committed to learning over a lifetime. The ego has a funny way of keeping humility at bay circling back to the frustrations seen in outliers such as myself.

@MSDeltaFlt I'm not knocking you, and I have zero clue what sort of provider you are. What I am saying is progression is a result of reflection, and not the other way around. There's just absolutely no way for us to call this a practice if we're not keeping an open mind, especially when time and time again we're seeing improvements with technology such as VL, and its many manufacturers.

Equipment is equipment regardless of the type, so again, none of us understand what it is you're trying to prove. You check it like you would any other piece of equipment--frequently. As far as technique, while as @StCEMT pointed it out, I think we're all pretty much in agreement on the importance of proper basic airway adjuncts and manuevers. Your testimonial remark has no place in this thread.

Back on topic~ I think one attempt with VL, then straight to a modernized blind airway is the near future, if not strictly SGA's. Aside from the services who actively practice routine, adequate airway training.


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## Carlos Danger (Apr 29, 2018)

As I said before, I am pretty confident that the time is coming that VL will be considered the standard of care, and DL without a good reason will thus be considered substandard care. 

At one time, the same arguments that are currently being used against VL were used against Sp02, EtC02, and ultrasound.


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## NPO (Apr 29, 2018)

Remi said:


> As I said before, I am pretty confident that the time is coming that VL will be considered the standard of care, and DL without a good reason will thus be considered substandard care.



I can't believe that VL isn't already the standard of care. The only arguments against are dogma and cost. Neither of which are significant.


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## StCEMT (Apr 30, 2018)

My first pass success with VL + bougie this month is 100%. I just finished a call that I intubated and after clearing the airway it was as smooth as I could hope for. I still will use DL, but VL has been making a trend as my first line option lately and my results are definitely better with it.

I didn't ignore technique though. I just used the appropriate method with the equipment I used.


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