# Is this normal? - ET Tubing



## mcdonl (Oct 1, 2010)

So, first three attempts... I successfully get the tube in the esophagus....

Instructors shows me, I get the stomach again.... he says just quit, I am not cut out for it (You have to know him to love him....) 

Then...

He Suggests.... "Don't stick the blade in so far, and try to pry the mandible off the skull and you may have better luck...."

I also took the time to envision the anatomy upside down, and by the end of class I could do the tube in less than the required 30 seconds! 

It was a roller coaster ride indeed but man, didn't it feel good!


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## exodus (Oct 1, 2010)

Look for the vagina in the throat!


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## akflightmedic (Oct 1, 2010)

Here is a great piece of advice for you as well.

In practice or in real life...if you ever stick the tube in the esophagus, do NOT remove it!

Leave it in place, grab a second tube and this time go for the hole which does not have a tube sticking out of it.


Make sense?

There is never really any prying when using the laryngoscope. You need to lift up and away from yourself to properly visualize.


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## WolfmanHarris (Oct 1, 2010)

akflightmedic said:


> Leave it in place, grab a second tube and this time go for the hole which does not have a tube sticking out of it.



Best and most obvious (once you hear anyways) piece of intubation advice I've heard yet.


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## usalsfyre (Oct 1, 2010)

Plan on spending as much time as necessary with Fred the Head till you can intubate him upside down, backwards in the dark with any blade that is big enough to move the anatomy needed. Why? Because other than the motions involved, intubating a dummy is nothing like a true human. There is a notable lack of slimy stuff in the dummy, as well as the fact that his anatomy is perfect, stiff and structured and in the same place all the time. 

So why, if practice doesn't resemble real life, is practice important. Simple, if you have the actual, physical manipulations required to pass a tube down pat, your much more free to focus on controlling the tongue, locating the appropriate anatomy and passing the tube, rather "am I doing this right". 

I highly, highly recommend viewing the Airway Cam videos if you have access to them as well. While it's not actually manipulating anatomy, you will get to see a lot of different sets of cords in real patient populations. 

Hopefully your program actually includes a chance to intubate real, live humans in a controlled environment with close supervision. If not, be aware that what your getting is akin to playing paintball a couple of time and then going out and getting into a gunfight, with real, deadly consequences. Understand that no matter what, you are woefully under-prepared to be managing airways by yourself, and seek to improve at every juncture.


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## FLEMTP (Oct 1, 2010)

usalsfyre said:


> Plan on spending as much time as necessary with Fred the Head till you can intubate him upside down, backwards in the dark with any blade that is big enough to move the anatomy needed. Why? Because other than the motions involved, intubating a dummy is nothing like a true human. There is a notable lack of slimy stuff in the dummy, as well as the fact that his anatomy is perfect, stiff and structured and in the same place all the time.
> 
> So why, if practice doesn't resemble real life, is practice important. Simple, if you have the actual, physical manipulations required to pass a tube down pat, your much more free to focus on controlling the tongue, locating the appropriate anatomy and passing the tube, rather "am I doing this right".
> 
> ...



This is a good piece of advice.

I dont understand for the life of me... how or why anyone or any organization would do anyone the disservice of putting on a paramedic class with no real hands on human intubation experience in it?

I also dont understand why anyone would shortchange their education by attending a class that didn't let you actually intubate a real person.. or several real people!


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## TransportJockey (Oct 1, 2010)

FLEMTP said:


> This is a good piece of advice.
> 
> I dont understand for the life of me... how or why anyone or any organization would do anyone the disservice of putting on a paramedic class with no real hands on human intubation experience in it?
> 
> I also dont understand why anyone would shortchange their education by attending a class that didn't let you actually intubate a real person.. or several real people!



Here in NM it's a problem of actually getting OR time, sicne the hospitals are largely going to LMAs for their elective surgeries. There is only one hospital that allows students into it's OR in the entire northern 2/3s of the state (not sure about southern NM at all) and since it has a med school attached, they would rather get their med students and CRNAs rotation time. I didn't get my first tube until internship.


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## usalsfyre (Oct 1, 2010)

jtpaintball70 said:


> Here in NM it's a problem of actually getting OR time, sicne the hospitals are largely going to LMAs for their elective surgeries. There is only one hospital that allows students into it's OR in the entire northern 2/3s of the state (not sure about southern NM at all) and since it has a med school attached, they would rather get their med students and CRNAs rotation time. I didn't get my first tube until internship.



I think this is another case that comes back to educational quality and what's better, a few programs putting out high quality, well prepared and rounded graduates, or a lot of programs pumping folks through. Until we can get the states to recognize this fact though, the educational debasement will continue.


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## TransportJockey (Oct 1, 2010)

usalsfyre said:


> I think this is another case that comes back to educational quality and what's better, a few programs putting out high quality, well prepared and rounded graduates, or a lot of programs pumping folks through. Until we can get the states to recognize this fact though, the educational debasement will continue.



I agree. And I would put the medic program I went through up against any in the nation in terms of quality. The ET tube situation is the only point where it has problems, but that's a NM thing due to us just not having a lot of hospitals. Hell we only have 1 Lvl1 in the entire state! Man I got weird looks when I was in Denver when I said that


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## usalsfyre (Oct 1, 2010)

Dangit, I'm gonna sound like Ventmedic but....

Do you think if there were fewer crap programs around more hospitals might allow students to do clinical time there? Just a thought.


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## CAO (Oct 1, 2010)

jtpaintball70 said:


> Here in NM it's a problem of actually getting OR time, sicne the hospitals are largely going to LMAs for their elective surgeries.



Same around here with the LMAs.  During our clinical orientation, we were told to count them as intubations anyway.  On top of that, we only have to have five of them.

Unfortunately, I saw the eyes of the bare minimalists light up upon hearing that.


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## TransportJockey (Oct 1, 2010)

CAO said:


> Same around here with the LMAs.  During our clinical orientation, we were told to count them as intubations anyway.  On top of that, we only have to have five of them.
> 
> Unfortunately, I saw the eyes of the bare minimalists light up upon hearing that.



They wouldn't consider that with us, mostly cause we'd been using LMAs since day one of Basic class, same with MLAs. I'm glad they didn't cause then we would have had people slack off even more and be content that they could jsut use LMAs or Combis (which I know have their place, and I'm even inclinced to grab a King or Combi if it's a tough airway and don't have a lot of time)


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## TransportJockey (Oct 1, 2010)

usalsfyre said:


> Dangit, I'm gonna sound like Ventmedic but....
> 
> Do you think if there were fewer crap programs around more hospitals might allow students to do clinical time there? Just a thought.


Out of two hospital systems (3 hospitals each) plus the state lvl 1 trauma in Albuquerque, we could do clinicals in 1 of the systems and the trauma center. The other hospital system (which I worked for at one point) didn't let medic students do clinical time there because they took the majority of the nursing students and didn't have the space to let medic students in.

In NM we are lucky that we have no real medic mills. We have 2 AAS programs and 1 BS-EMS program. I think there might be a certificate program still in the eastern part of the state too, but they are all run and operated by community colleges or 4 year schools.


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## MasterIntubator (Oct 1, 2010)

exodus said:


> Look for the vagina in the throat!



Ehh ehh.. I like you.  Awesome, made my day.... hope its not copyrighted... cause I'd like to use it. 

Wow AKflight.. have not heard that in a loooong time.  That is something we used to practice regularly with EOAs.  I loved the EOA... it plugged the puke hole, and it was a great bite block after intubating.  <sigh... memories.. >

orig post... keep practicing, it will come.  Sometimes you have to change your technique up a bit... the 'book way' is not always the best way for you.  Try different handles, different angles, use different muscles in your wrist and arm.  Since its sometimes heard to explain, I'm gonna try to shove some pics up for you.  I tend to hold near the laryngoscope joint, its more relaxing, and makes me use a different angle.  Sometimes you have to get an extra 'toy' to make it work well for you.  Look at other folks' technique... try it out. There is one out there for you.


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## MasterIntubator (Oct 1, 2010)

And.. some more... showing just my hand placement on the set.  I use a peds handle with whatever blade I choose to use.  
The second ( pic 2 and 5 ) just shows a Howland lock, which just gets rid of the 90 degree tooth breaking angle in tight cavities. ( just one of the toys that makes it easier for me )

Hopefully you will find yours.


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## akflightmedic (Oct 1, 2010)

You calling me old???

I am just amazed at how students are not taught different techniques. Intubating does not require you to get on your belly to do you "thang". I see so many people get locked into one method and that is all they stick with never venturing to try something different.

Pad under the pts shoulders, pull them to end of table, bed, stretcher, whatever it is and let gravity work with you! When you let them hang so they resemble a Pez dispenser, it is amazing how little laryngoscope help you need.

Sit them up in semi-fowlers and stand behind them. Try it, it works!

Have a partner stand over the patient and A) lift them by the arms to allow head to fall back or B) straddle the patient and insert the laryngoscope and let your P use his force and better angle to open the airway and all you have to do is tag the hole. (Hatchet method)

There are so many different ways to become better at it including making it a team sport! Never be afraid to ask for help or hand off if it just is not your day. This is not about you or your ego, it is about the guy who is not being ventilated.

Thought I would throw in a few more tid bits, hope ya'll don't mind.


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## Aidey (Oct 1, 2010)

I love telling students about leaving the esophageal tube in...It amuses me to watch the light bulb go on in their head. ^_^ Two holes...one is already plugged...lol 

Our medical directors are pushing the "most appropriate airway" rather than "the most advanced". They want people thinking about CPAP and the King instead of just ETI ETI ETI. There has been talking of getting the recert rules changed so that instead of a certain number of ETIs a year, all of your advanced airway interventions are looked at, so CPAP and Kings count too. You would still be required to have some ETIs, just not as many.


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## Veneficus (Oct 1, 2010)

usalsfyre said:


> Dangit, I'm gonna sound like Ventmedic but....
> 
> Do you think if there were fewer crap programs around more hospitals might allow students to do clinical time there? Just a thought.



I think at one time that might have been true. But there are a host of factors in play now.

As was pointed out, there are fewer tubes going around. In the hospital, with attendings, residents, RTs, CCT teams, etc. The field medic in most places is at the very bottom of the list. A medic student even lower.

Medicare doesn't help either. They no longer pay for complications that are considered "preventable." Insurance companies often don't pay for anything medicare won't. That means the hospital eats the cost of anything that goes wrong. Not exactly a proeducation environment.

There are simply too many paramedics. The US is saturated in many parts. In some areas everyone who wants to even fill out a fire application has to be a medic first.  have seen a department with 70 medics on roster and average 10intubations a year in the whole service. Even if you wanted all those people to get a tube in the hospital, it may not be possible.

Even for medical students, it seems in the US they are permitted to do less and less every year. If nobody is going to let somebody with at least 2 years of graduate medical education touch a patient, who is going to let a paramedic student? 

Brave men and their proud simulators. There is big money in simulation. There are major efforts underway, including a bill making its way through congress that will mandate every provider must recertify skills in "official" sim labs every few years to qualify to get reimbursed via medicare. I know one of the authors and he claims that simulation technology is the safest way to practice. Very true, but you will never hear him say the "most effective." He is also on the payroll of a company that makes a lot of money in medical simulation. What a coincidence...

If you really need Fred the head to be more realistic, cut the tongue away from the base of the mouth, spray 1/2 can of lube in there and then dump in some campbell's chunky vegetable soup. Makes one hell of a mess, but a way better simulator than an unmodified Fred the head.

I think at this point even if you cut out all the "suspect" and diploma mills, it wouldn't change much. About the best you can hope for is a cadaver lab. But they come with a premium price too.


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## MasterIntubator (Oct 1, 2010)

Ehh ehh ehh .... I always get the deer in the headlights stare from youngers when I talk about stuff like that... so.. I guess you can say that I called you 'old'  

Someone earlier brought up about what they teach these days in class... and it does seem the whole airway thing is just another chapter with minimal skills practice.  It used to be the most studied and practiced with tons of options and ideas.


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## usalsfyre (Oct 1, 2010)

Aidey said:


> I love telling students about leaving the esophageal tube in...It amuses me to watch the light bulb go on in their head. ^_^ Two holes...one is already plugged...lol
> 
> Our medical directors are pushing the "most appropriate airway" rather than "the most advanced". They want people thinking about CPAP and the King instead of just ETI ETI ETI. There has been talking of getting the recert rules changed so that instead of a certain number of ETIs a year, all of your advanced airway interventions are looked at, so CPAP and Kings count too. You would still be required to have some ETIs, just not as many.



I'm all about the most approprite airway, from simple stimulation up to and including surgical cric. But....

CPAP is not an airway intervention. In fact, if the pt is not fully in control of their airway it's totally inappropriye and dang near negilgent to place a sealed mask over the patients airway. An incredibly useful adjunct to oxygenation and vetilation, absoloutely. Staves off a large number of intubations, sure. An airway control device, not by a long shot.

Further, dropping. King or LMA is not equivilant to placing an ET tube under direct larengoscopy. The fact that paramedic programs and medical directors are saying they're the same, and then letting folks go out and place ET tubes when they may have not have done DL in months or years scares the crap out of me.


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## CAO (Oct 1, 2010)

usalsfyre said:


> Further, dropping. King or LMA is not equivilant to placing an ET tube under direct larengoscopy. The fact that paramedic programs and medical directors are saying they're the same, and then letting folks go out and place ET tubes when they may have not have done DL in months or years scares the crap out of me.



Glad I'm not the only one.



Veneficus said:


> Even for medical students, it seems in the US they are permitted to do less and less every year. If nobody is going to let somebody with at least 2 years of graduate medical education touch a patient, who is going to let a paramedic student?



I saw the same attitude with IVs.  To get my EMT-IV license, I needed to get 5 IVs, 3 I think with fluid administration.  A lot of the places I went to on clinical rotations hardly wanted me to touch a patient, let alone perform an invasive procedure.  I was struggling towards the end just to get those 5.


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## Shishkabob (Oct 1, 2010)

Shoot, I did every IV on every patient that came in to my clinical locations, even if it was a crashing kid.


Now... number of tubes I got?  We won't go there.


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## mcdonl (Oct 1, 2010)

Thanks everyone. And we do practice in the dark, a car, etc ....

Also, we do 24 hours in an OR for the purpose of airways.


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## Aidey (Oct 2, 2010)

usalsfyre said:


> I'm all about the most approprite airway, from simple stimulation up to and including surgical cric. But....
> 
> CPAP is not an airway intervention. In fact, if the pt is not fully in control of their airway it's totally inappropriye and dang near negilgent to place a sealed mask over the patients airway. An incredibly useful adjunct to oxygenation and vetilation, absoloutely. Staves off a large number of intubations, sure. An airway control device, not by a long shot.
> 
> Further, dropping. King or LMA is not equivilant to placing an ET tube under direct larengoscopy. The fact that paramedic programs and medical directors are saying they're the same, and then letting folks go out and place ET tubes when they may have not have done DL in months or years scares the crap out of me.



They aren't saying they are the same, they are saying they want people to use their heads and use the most appropriate. If CPAP will work, don't RSI the patient to get the tube. If the pt has a malampati of 4, and you've looked and can't see crap, don't try ETI 5 times, use a King.


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## usalsfyre (Oct 2, 2010)

Aidey, I applaud your medical direction for pushing this line of thinking. Airway SHOULD be a continuum, and not every patient will get an ET tube in the field. The one flaw in the approach your talking about is that the number of ETIs needed to maintain proficency does not decline because of CPAP and Kings. If anything you need to be more proficent, as your patients will be sicker when they need an ET due to CPAP. So reducing ETIs in favor of Kings and especially CPAP (really, it's sealing a mask, I could teach my three year old the skills behind it) is cheating your providers and patients.

My $0.50 worth for systems is either keep your folks up to speed on ETI, or get rid of it.


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## Aidey (Oct 2, 2010)

I know, that is the downside of the whole situation. The problem is that right now there are not enough intubations happening so that every medic and medic student can meet their total number needed. We are allowed a certain number on a mannequin, but the demand is still higher than the number of tubes available. I think they hope that by pushing the idea of the most appropriate intervention rather than the most advanced they hope to reduce the competition existing in the current system. When you are dealing with some 250 or so paramedics reducing the number of tubes required on a real human by 2 a year can made a difference hopefully without compromising quality. 

I think that simply requiring that capnography be used on every intubated patient would be a big step in the right direction. And I mean required. You have one free pass, and after that if you don't use it, you don't get to intubate.


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## Veneficus (Oct 2, 2010)

usalsfyre said:


> My $0.50 worth for systems is either keep your folks up to speed on ETI, or get rid of it.



I wish more people would think like this.


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## usalsfyre (Oct 2, 2010)

Aidey, I agree on waveform capnography. Any service that intubated and doesn't have it is negligent. Anyone who has it and won't use it on intubated patients needs to be whipped with a capnograph line until they have a change of heart.

I don't know how your system is set up, but the question that comes to mind is do all of your medics need to be able to intubate? Or would it be better to have the majority of them utilizing blind airways with a select few able to do ETI? This would ensure a higher level of oversight, and much more hands on time with a laryengoscope for the people who can intubate?


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## Aidey (Oct 2, 2010)

lol, I like how you think...I just threatened to whip someone with a NRB the other day 


Realistically no, not all of the medics need to be able to intubate. However, no one will EVER be able to convince any agency to give it up or self limit. If my agency or medical director even suggested it, I know exactly what would happen. It would hit the media as either we aren't providing the same care as the FD, or that we are trying to limit the care the FD can provide. 

The only way I could see it happening is if the medical directors collectively tell all the agencies "this is how it is going to be, suck it up and deal with it". I think the only way they would do that is either as a result of a lawsuit or because intubation success rates suck. 

The other problem is that our state requires a certain number of intubations in order to recert, so that would have to be changed if they wanted to limit who can and can't intubate. 

Now that all of the local ALS agencies have capnography the MDs are really starting to push it, and push the ERs into using it too, even if the RT isn't there. I think that it will take some time, but hopefully there eventually will be a mandatory use policy in place. It also wouldn't surprise me to see more lawsuits against agencies who don't have it, since it is becoming the standard of care. If we want to keep ETI as a pre-hospital skill capnography needs to be universal. 

I have a personal policy that if I intubate someone they will be put on  capnography. Period. I will use an OPA and BVM until it is available. In  a perfect world it will be used on all intubated patients in my  presence, whether I tube them or not. That policy actually recently  saved my butt in a big way, so it won't be changing any time soon.


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## 18G (Oct 4, 2010)

My program was lucky to be able to do rotations in the OR. We had to do 16hrs which isn't much at all but you were almost guaranteed to get at least two intubations on real patients. And the ED physicians were cool about letting the Paramedic students intubate. 

During our airway class we had an "airway rodeo"... this was where the instructors set the mannekin's up in atypical situations and we had to intubate them... some where upside down, in complete darkness, in a car pressed against the steering wheel, etc. It was a good experience and added some perspective of what real-world field intubations would be like.

To the OP.... its true that sometimes you only succeed after you fail. Even though you missed the tube you still got a first hand look at the airway anatomy, gained perspective of the airway, and experienced the motion of the procedure. As long as you can reflect on all of that its not really a failure when it happens during your clinicals. I admit its blows your confidence to pieces but its your time to learn. 

As a student I had a patient in the ED that needed intubated and the doc allowed me an attempt... so here I am nervous, with a room full of staff people looking on, and I miss it... but looking back I can now see the esophagus that I intubated... it looked nothing like the trachea now that I am a little more versed with the airway structures. What I learned from that failure was how distinctly different the trachea and esophagus look and what it means when some people say "that patient was really anterior". This patient was and the doc even said so after the fact. With some cricoid pressure it would have brought the cords into view... lesson learned. 

It will come... don't let it get you down.


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## mcdonl (Oct 4, 2010)

Thanks 18G... it is coming to me. I was more frustrated with an exam score I got last week! Good grades take more than just smarts, you have to study!! Which, is what I need to get back to right now.


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## SignorSchnitzel (Oct 4, 2010)

exodus said:


> Look for the vagina in the throat!



hahahaha 100% yes, exactly!


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