# Intubation facts when performed on our own



## VentMedic (May 22, 2008)

I saw this on another forum and after reading it I feel compelled to share the information on this forum.   I believe more emphasis should be on thorough initial training and competency maintenance closely monitored when it comes to intubation.  

*Fire Fighter Fatality Investigation and Prevention Program*

http://www2a.cdc.gov/NIOSH-fire-fig...Related=0001&Trauma_Related=ALL&Submit=Submit

These are cardiac and not trauma related deaths.

The information by NIOSH is largely about FF fitness for duty.   However, the medical data for intubation success that was discovered during the investigation is disturbing.

I am quoting the findings of mitllesmertz1  from the forum EMSresponder.
http://forums.emsresponder.com/showthread.php?t=95563

You can read through the investigative reports and also confirm what he has found. 




> Total of 22 reports where CPR was initiated and ALS measures were implemented, from roughly 2005 through 2007.
> I counted reports where an "advanced" airway was attempted ( there were a few combitubes placed).
> Here's what I found:
> 
> ...


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## Doughboy (May 22, 2008)

While that success rate isn't good, 22 tubes is a pretty small sample size.


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## el Murpharino (May 22, 2008)

Doughboy, there have been numerous studies published that highlight the low success rate of intubation by prehospital providers.  This is a national problem, and one that needs to be addressed now.  People aren't educated as properly as they should be, and fail to maintain proficiency once they are trained.  Some systems maintain that their paramedics perform "X" amount of successful intubations per year to maintain their card....yes I know this isn't feasible in rural and even suburban areas, but there needs to be some sort of proficiency training in place to keep this trend from happening.  OR time, cadaver labs, ER time, heck...some of these new simulators they come out with nowadays are downright tough...but there needs to be something put in place to keep up a skill some providers only do once or twice a year.

Here's a few sites highlighting this trend:

http://emj.bmj.com/cgi/content/abstract/22/1/64

http://ccforum.com/content/10/s1/p64

http://content.healthaffairs.org/cgi/content/abstract/25/2/501


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## Doughboy (May 22, 2008)

Thanks, Murph... you'll notice I didn't comment on how good or bad EMS is at intubating.  I'm familiar with both the extent of the problem and the barriers to improving the success rate.  However, note that all 3 studies you linked me to report a pre-hospital intubation success rate of 70 to 80 percent, versus the 50% some guy found while sorting through reports.  The law of large numbers applies.  The outcome of 22 intubation attempts in a pool of hundreds of thousands of EMS tubes per year is, simply put, not a representative sample.


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## VentMedic (May 22, 2008)

This were incidental findings for FFs and from their cardiac events.      

It reminds me of an article published not to long ago on the chances of surviving an inhospital code.   For a couple of these investigative reports, there should have be FR or some ALS on standby since they were fire scenes.    *If you missed a tube on one of your co-workers*, I believe that would be "significant" regardless of the whole sample size.

The ability to intubate should be a skill that is performed frequently enough in some setting for proficiency to where it is second nature so that the focus is then other ALS skills while knowing the airway is secure.


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## mikeylikesit (May 23, 2008)

I agree completely. i also think that it should become a basic skill as well so that the medic on scene can attend to other things. the lma and combitubes are great and all but they are too hard to place on sealing airways from trauma or shock. i would much rather take 2 stabs then having to fight a simple tube for a minute.


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## Ridryder911 (May 23, 2008)

What I do NOT understand is why intubations keep arriving in ED in the wrong place? With so many detectors such as EtCo2 w/waveform; one can immediately detect lost of tube placement and still good assessment techniques. 

I am totally against EMT Basics performing any more "skills". Why would we want to allow lower license/certified individuals to attempt such procedure if one with higher and more in-depth education, already have poor outcomes?  Even the most simplistic "skills" can be overwhelming. to many basics, just read the posts They are trained for "basic" maneuvers, they have very little to no anatomy and physiology, no introduction to critical thinking skills and we want to place more, especially intubation on a 150 hour trained individual? That's not fair for them, the system, nor the patient! 

Again, we are trying to mix skills with education level and performance, outcomes. One cannot do such. 

R/r 911


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## mikeylikesit (May 23, 2008)

true, i took basic school so long ago that i cannot remeber what was learned. i think that it seems so basic for me know that it is common knowledge. but i would beg that an intermediate should not to be able to intubate either due to the fact that they usually only get another 150 hours of training in which they have to remeber a ton more complex algorithims and such. i do agree though that they should spend a little more time in the intubation portions of medic schools.


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## Ridryder911 (May 24, 2008)

I understand that, but really is even150 hours long enough? Apparently, how and what we are teaching is NOT working... Maybe, airway techniques alone should be 150 hours. I know my intubation clinicals required 24 adult, 10 child, and 2 pediatric. Yes, they were hard to obtained and yes it stressful. The whole point, as one of the contributing factors of performing a skill successfully is feeling confident, in which I did.

R/r 911


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## bonedog (May 24, 2008)

I can see why some service's have trouble with intubation.


http://www.youtube.com/watch?v=rv-uWXo4xzU&NR=1

 20 years and he cann't recognize VF induced seizures, not even so much as a precordial thump.....


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## firecoins (May 24, 2008)

Ridryder911 said:


> I know my intubation clinicals required 24 adult, 10 child, and 2 pediatric. R/r 911


  Whats the difference between a child and pediatric?  Do you mean neonate?


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## MasterIntubator (May 24, 2008)

At least in the video, they had a partial rebreather on during the arrest. 

Instead of calmly humming and effectively intubating, most folks rush and do haphazard work. Now this, this right here... is where our stats kill us in the field.
If you miss.... No biggie, pull out and start bagging or use another tool.
It is an art, and most of it is in your attitude, demeanor and requires you to be calm and effective. There is no way around it.
In the surgical suite, the anesthesiologists are about as calm as anything, drives many medics nuts! 45 seconds went by since the last ventilation, and they are talking about breakfast while slowly grabbing their tools. They know 2 minutes will not harm a patient with a non-complicated airway ( as most are non-complicated ), and they can have the tube in right after do the direct laryngoscopy. ( 5-10 seconds )... without a drop in SaO2. ( thats another subject ). --- Point is... you have time!


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## MedicPrincess (May 24, 2008)

MasterIntubator said:


> In the surgical suite, the anesthesiologists are about as calm as anything, drives many medics nuts! 45 seconds went by since the last ventilation, and they are talking about breakfast while slowly grabbing their tools. They know 2 minutes will not harm a patient with a non-complicated airway ( as most are non-complicated ), and they can have the tube in right after do the direct laryngoscopy. ( 5-10 seconds )... without a drop in SaO2. ( thats another subject ). --- Point is... you have time!


 
During my OR clinicals, a few of us were assigned to the anesthesiologist we called the "10minute" Dr.  On our first rotation with him, he would spend about 30 minutes with us educating us about calming down, taking our time, and realizing we actually have about 10 minutes to get the patient intubated.  He went on to explain when you have a properly "denitrogenated" (did not like the term preoxygenate.....long explanation) patient, you can take your time.  He explained the percentage of of O2 drop each minute a pt is not breathing... ect.

When we got into the OR, on our first patient with him he would first make us bag the patient for what seemed like FOREVER....but was actually about 2-5 minutes, depending on his assessment of your ability to properly do it.  Then he would be talking..... at one point he said, "I could leave the pt, walk to the cafeteria and get another cup of coffee, and come back.  I would still have time to get her intubated without any need to rush."

I asked him how that would apply in the field, where we are not working under the same conditions as a wonderfully prepped surgical patient.  He told me is comes down to simply taking time to properly bag the pt to ensure maximum denitrogenation.  He asserted, even in a cardiac arrest patient.

I feel like it has helped me.  Granted, I have yet to excercise my "10 minutes" on my apenic patients, however even as new as I am I have yet to get that Oh Crap I better get this done now going on.  I know I have driven my EMT's with me, and even some of the ALS providers, absolutely nuts when I RSI'ing or getting ready to intubate.  I have been told on more than 1 occasion, I need to show more of a sense of urgency in getting it done.  When we talk about it, they all have said it took me "forever" to get it done, when in reality it hasn't, it just wasn't a paniced rushed thing.


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## MSDeltaFlt (May 24, 2008)

One of the trauma attendings where I took my critical care course told us in a lecture, "It takes at least 10 'atta-boys' to fix one 'oh-sh*tter'".  He was referrencing to any mistakes made, but it can also be make towards the mindset.  If you ever think "oh sh*t", then you'd better start making some "atta-boys"... quick.

If you're ever "b*lls-to-the-wall" on *anything*, you're automatically behind the 8 ball.

The competent get the job done.  The good get the job done regardless of the situation.  The damn good get the job done regardless of the situation, and get told how easy it looked by their peers/superiors.

That's where I want to be when I grow up.


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## emtlady76877 (May 24, 2008)

I think intubation should not be performed by a basic even though I have been practicing and I can now intubate in less than 30 seconds on a mankin. I am not good enough to go out in the field and intubate yet because i can only use a mac blade and I still need a stlylete. My instucter says until you can use either a mac or a miller and no stylete you are not readyto intubate on a real person and I agree. The more I learn in my paramedic class the more it scares me to stay a basic. I want to hurry up and become a paramedic. FYI the paramedics are responsibable for what the basics do under them according to the Borrowed Servant Doctrine. You may be liable for any negligence act they comment. So are you going to let a basic intubate under you?


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## bonedog (May 24, 2008)

Princess, I like the fact in the OR you are made to ventillate the patient, this is an aquired skill that many cann't do. As they say if you cann't do the basic's...

With new CPR, tubin' should be the last thing to worry about.

As for the video, personally, I would probably do a pulse check at least before I tried to get the patient to stand.

I know scoop and run is in vogue again, however, I like an IV with my TV.


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## Ridryder911 (May 24, 2008)

Actually, child was < 12 and pediatric < 3 years of age, infant < 1 year of age, neonate < 1 month of age. 

I always describe airways as ..easy, hard, and OH H*ll ! Alike, what has been discussed preparation both mentally and equipment is part of the key. 

With the introduction of such devices as EtCo2 waveform and monitors, good patient assessment there is NO reason to deliver a patient with an ET tube in the gullet. Want to present a poor representation of what EMS is.. there ya go ! 

It is our standard to run a EtCo2 strip upon arrival to ED; documenting that ET was properly placed. This immediately stopped the display of residents attempting to acclaim that the arrival of the patient was not properly intubated. In fact, our intubation rates in comparison (even without the use of RSI) was remarkably higher > 72%. Again, even being a "small" service realize the potential of innuendos. 

Again, proper education and re-enforcement through refreshers, and good CQI. After encouragement, we finally placed flex guide (Bougie elastic guide) which also adds to increased successful intubations. After implementing them, large metro EMS in my area now has a 99% intubation rate... not bad for over 175,000 calls a year. Of course one does not read about the millions of successful intubations... I do wish Wang would get a hobby or a life, almost of all of his studies has always emphasized poor outcomes in EMS. Ironically, I do not recall reading any other studies produced by him.

Personally, I believe intubation is easier than placing a NG tube. Again, it is not the skill that not only needs to be emphasized but the entire airway system. Understanding detailed anatomy, landmarks, and a full understanding of the airway respiratory pathophysiology is the key to making procedures and treatment successful. 

R/r 911


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## MedicPrincess (May 24, 2008)

emtlady76877 said:


> My instucter says until you can use either a mac or a miller and no stylete you are not readyto intubate on a real person and I agree.


 
I knew there was something else!!  He also wouldn't allow a stylette.  Again with the long explanations as to why you don't actually need a stylette.....

That was probably the best thing for me.  Even as an EMT setting my partner up for an intubation....and now when I am getting my own stuff together...... I ALWAYS forgot to put the damn stylette in.  

I can say though, I don't get nearly enough intubations.  I had 5 last month, but before that it had been 2 months before I had one....and now its almost a month since my last.  Those 5 were all cardiac arrests (3 that coded in front of us).  Its been 6 months since I RSI'd someone....


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## Ridryder911 (May 24, 2008)

MedicPrincess said:


> I knew there was something else!!  He also wouldn't allow a stylette.  Again with the long explanations as to why you don't actually need a stylette.....
> 
> That was probably the best thing for me.  Even as an EMT setting my partner up for an intubation....and now when I am getting my own stuff together...... I ALWAYS forgot to put the damn stylette in.
> 
> I can say though, I don't get nearly enough intubations.  I had 5 last month, but before that it had been 2 months before I had one....and now its almost a month since my last.  Those 5 were all cardiac arrests (3 that coded in front of us).  Its been 6 months since I RSI'd someone....



Any device that can aid to successful intubations should be encouraged not discouraged!  Easy to say such an asinine statement when one is in a 55 degree room, where the tube is always rigid and non pliable one should not have to use a styllette, let's see them say that 95 degrees and outside in a bright light. Of course Anesthesiologist are also used to pre- medicate to prevent secretions, paralyzing agents, and of course examining the patient prior to intubation. 

Part of the problem we have in EMS. It is called Cowboy medicine.. we need to leave the ego's at the door. Personally, I too forget about placing the styllet in prior, but feel like a fool when I do have to stop and then place one in. Any tool or device that can increase my success I am in favor of. 

R/r 911


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## firecoins (May 24, 2008)

emtlady76877 said:


> I. My instucter says until you can use either a mac or a miller and no stylete you are not readyto intubate on a real person and I agree.



Is your instructor advocating no stylette?


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## VentMedic (May 24, 2008)

MedicPrincess said:


> I knew there was something else!!  He also wouldn't allow a stylette.  Again with the long explanations as to why you don't actually need a stylette.....






Ridryder911 said:


> Part of the problem we have in EMS. It is called Cowboy medicine.. we need to leave the ego's at the door. Personally, I too forget about placing the styllet in prior, but feel like a fool when I do have to stop and then place one in. Any tool or device that can increase my success I am in favor of.
> 
> R/r 911



I had to learn to intubate without a stylet for Flight and specialty transport including NICU. 

In L&D you are expected  to be able to intubate the meconium babies quickly with at least two passes and a stylet can get in the way.  You have to do this before that baby decides he/she wants to take that first big breath. 

The point the doctor was probably trying to stress, especially in emergent situations,  is that a stylet is not always necessary.   I have seen too many paramedics and others (RTs, MDs, PAs, NPs) actually lose focus and go to pieces because some piece of equipment like a stylet is not available.  I'm sure this Anesthesiologist has seen this happen many times while training all the different professionals.  By introducing a new intubator to this actually can make them stronger in the long run. 

If it is available, use it.  If for some reason you don't have it, you should know that you can still accomplish the task if necessary.


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## emtlady76877 (May 24, 2008)

He wants us to be good enough that we can intubate with or without a stylette with a mac or a miller blade,because someday you might have a case where there is not a stylette available.


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## MedicPrincess (May 24, 2008)

VentMedic said:


> The point the doctor was probably trying to stress, especially in emergent situations, is that a stylet is not always necessary. I have seen too many paramedics and others (RTs, MDs, PAs, NPs) actually lose focus and go to pieces because some piece of equipment like a stylet is not available. I'm sure this Anesthesiologist has seen this happen many times while training all the different professionals. By introducing a new intubator to this actually can make them stronger in the long run.
> 
> If it is available, use it. If for some reason you don't have it, you should know that you can still accomplish the task if necessary.


 
Exactly!!  As an EMT, I watched my partner at the time have her entire "groove" thrown off when I would forget to put the stylette in place.

The last code I had last month, as I went to intubate I realized I had forgot the damn stylette again, but was still able to effectively and on the first attempt pass the tube.

I would consider it adapting to your surroundings.  Things happen.



> Part of the problem we have in EMS. It is called Cowboy medicine.. we need to leave the ego's at the door.


 
I see that all the time.  However, I have been informed that my "ego" is not "big enough" to be a good paramedic.  I don't consider it a personal failure if I cannot get an IV, and will not use my patients as pin cushions in the attempt.  I practice the 2 attempts to intubate before going to the King Airway, and on one patient went straght to the king as I could clearly see I wasn't going to get that tube.  I think my point is.... I know I have limitations.  I know I have a ton more to learn.  And apparently, I need to go find a larger Ego if I am going to "compete" with the Medics around me.......


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## Ridryder911 (May 24, 2008)

VentMedic said:


> I had to learn to intubate without a stylet for Flight and specialty transport including NICU.
> 
> In L&D you are expected  to be able to intubate the meconium babies quickly with at least two passes and a stylet can get in the way.  You have to do this before that baby decides he/she wants to take that first big breath.
> 
> ...



I understand that perceptive as well. I have seen too many that was taught or their success is dependent upon if they have a "Mac or a Miller".. Fortunately, I was taught that both is an excellent device.. hint: Alike said, never be dependent upon a piece of an equipment. 

The point I wanted to elaborate is that too many newer medics, now brag about "tubing" or some other procedure "without this and that".. and only to demonstrate otherwise. Apparently we have a problem, look at the results. I don't believe removing a "gold standard" skill because we have failed to educate properly. I also believe it would be wise to introduce and teach to use all available equipment, until they have totally mastered the skill. Even if one intubation is missed, that is too many. I carry a trigger tube, in my personal bag for work. I work in a predominantly area where the ethnicity make up have a "no-neck" syndrome, very anterior aspect. I have found it is much be better prepared than to have deal with the feces to the fan syndrome. 

Anesthesia unfortunately, have became are enemy instead of our allies in EMS education. As one that fully understands the risks of poor training and education, it would appear that they would only want and produce only the best. I had an EMS Instructor state meeting yesterday, and one of the topics was the difficulty on obtaining clinical sites. O.R. is one of the hardest and now almost all schools are having to pay for intubation clinicals. This is now making itself in other areas as well. I would hope that anesthesia professionals would at least be sympathetic and enforce to see that airway management is taught thoroughly and correctly. 


R/r 911


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## emtlady76877 (May 24, 2008)

I am also supposed to be able to look at a person and tell if he/she will be hard to intubate if they needed to be.


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## Ridryder911 (May 24, 2008)

emtlady76877 said:


> I am also supposed to be able to look at a person and tell if he/she will be hard to intubate if they needed to be.



Very true, few are taught Mallampati score, also Mallampati classification, Cormack-Lehane classes, as well LEMON. Each person that intubates should be very familiar summing up potential difficulties before they proceed. 

R/r 911


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## VentMedic (May 24, 2008)

emtlady76877 said:


> I am also supposed to be able to look at a person and tell if he/she will be hard to intubate if they needed to be.



As an RRT, I assess by the LEMON method ( (Look–Evaluate–Mallampati–Obstruction–Neck Mobility).   As RRTs we are QA'd constantly but have the advantage most of the time to pick the right equipment before an attempt is counted as a failure.   Our MD residents are also taught this so as the RRT we may be bagging for up to 20 minutes as the attending goes through all of his lecture and demo point.

http://www.rtmagazine.com/issues/articles/2007-03_03.asp

Receding chin, neck extension, mouth opening, teeth, tongue size and thyromental distance are some of the things to consider for intubation success predictibility.  

There is actually a whole scoring system that can be utilized and some anesthesiologists utilize it.

Darn Rid!  You quick!


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## MSDeltaFlt (May 24, 2008)

Rid, you're right, partly, about needing a cold room in order to intubate without a stylette.  Although you do require a cold room in order to get the ETT tip bent into the other end then to stay fixed in that position, what it also takes is PROPER POSITION.  Not just the pt with a pillow underneath their head plus the level of the bed must be at the proper height, but also YOUR proper position.  You also need to use your center of gravity and the like.  

When you do these things, you're able to intubate while not using a stylette.  It's just not very practical in the back of an ambulance... especially one doing 90.


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## Ridryder911 (May 24, 2008)

Your right about positioning. Some years ago (late 80's-90's) it was popular trick to intubate while laying beside your patient. It was very successful as it taught the value to get in position of your patient. So many do not understand the "planes" and right angles. Something we maybe not emphasizing enough. As you noted in positioning the patient. Another trick other than padding under the shoulders, is to place the pt. on a LSB and pull the patient up & slightly allowing the head to drop off (of course non-traumatic). 

Again, so many "rush" to get the tube.. when as long as your ventilating the patient well with supplemental oxygen, you can take the time to prepare your equipment and assess the patient, then verify (which is *very* essential both assessing with lung & epigastric sounds, and per mechanical EtCo2 detector. I highly suggest one with a wave form and print out (LP12 or similar) for documentation purposes & another tool for assessing. 

R/r 911


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## bonedog (May 24, 2008)

I also agree with Rid on the stylette. Having been one of those that was proud to never use a stylette, until the hot muggy day, watching the tube "wilt" as I tried to enter the anterior airway. Now I always put one in as I hate having to go in twice. 

I would never deny anyone any tool they require. Situations on the street an anethestist wouldn't encounter. Same with having the advantage of a premedicated, pre-oxygenated patient, as opposed to the hypoxic, acidotic, combative patient we are often accustomed to. ( next to never in a position of comfort either) 

The AIME course is excellent, covers all the adjuncts and LEMON.


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## MSDeltaFlt (May 25, 2008)

Ridryder911 said:


> Your right about positioning. Some years ago (late 80's-90's) it was popular trick to intubate while laying beside your patient. It was very successful as it taught the value to get in position of your patient. So many do not understand the "planes" and right angles. Something we maybe not emphasizing enough. As you noted in positioning the patient. Another trick other than padding under the shoulders, is to place the pt. on a LSB and pull the patient up & slightly allowing the head to drop off (of course non-traumatic).
> 
> Again, so many "rush" to get the tube.. when as long as your ventilating the patient well with supplemental oxygen, you can take the time to prepare your equipment and assess the patient, then verify (which is *very* essential both assessing with lung & epigastric sounds, and per mechanical EtCo2 detector. I highly suggest one with a wave form and print out (LP12 or similar) for documentation purposes & another tool for assessing.
> 
> R/r 911



Careful about the LSB and allowing the head to drop a bit.  If you over do it, it will act like hyperextending the neck making the trach more anterior.  As you said, it is easy to rush into a situation and make a difficult airway more difficult and end up shooting yourself in the foot.

You know you've had a difficult airway, either successful or not, when an anesthesiologist says he/she wouldn't have wanted to attempt tubing them.


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## bonedog (May 25, 2008)

A video clip in the AIME course shows placing a mobidly obese patient in a semi-fowler's position to align the planes and facilitate intubation.


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