Airway Management and Intubating without Drugs

FiremanMike

EMS Coordinator
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Not all of us are that bad, but the amount of times I have heard the phrase, "Bougies are for people who can't intubate" or "Why would i ever use suction?" Is pretty high. Curious if we are going to get the DeCanto suction though. That said, there isn't much incentive to improve aside from your own desire to better the patient, and you know how most of our co workers are.

In response to the thread, you basically have two options, be a bad medic and force the tube then sedate, or manage with a BLS airway and advise the hospital to have RSI ready. Had it happen to me earlier in the week, GCS of 7 with strong localization, and it's a choice of either doing something without the right equipment and medication, or manage the airway with an OPA and BVM.

As a side note, in general I feel frustrated more than satisfied in a lot of ways, we had a protocol update a year prior that never went into effect, still no official sepsis protocols, and a disincentive to using EtC02 for anything but pure respiratory reasons. I could list the things that frustrate for a while, but I'm starting to realise that the only thing I can do is improve my own practice as best I can.
Funny you say that about bougies - I’m phasing our regular stylets for bougies at work. I’ve always been a fan of the bougie, the study by Driver et al was pretty convincing evidence that it’s time to dump the traditional stylet..

I also recently put DuCanto tips in service..

As for your issues with End-Tidal, what's their motivation for devaluation? I'm guessing cost, which is unfortunate. Are they even aware of how widespread EtCO2 is becoming? Do they understand acid-base balance and WHY end-tidal is an indicator of an anaerobic metabolism (i.e. sepsis, poor perfusion, etc).. Very frustrating for sure, sounds like you're moving backwards..
 
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KingCountyMedic

Forum Lieutenant
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Funny you say that about bougies - I’m phasing our regular stylets for bougies at work. I’ve always been a fan of the bougie, the study by Driver et al was pretty convincing evidence that it’s time to dump the traditional stylet..

I also recently put DuCanto tips in service..

As for your issues with End-Tidal, what's their motivation for devaluation? I'm guessing cost, which is unfortunate. Are they even aware of how widespread EtCO2 is becoming? Do they understand acid-base balance and WHY end-tidal is an indicator of an anaerobic metabolism (i.e. sepsis, poor perfusion, etc).. Very frustrating for sure, sounds like you're moving backwards..
I don’t think you should be dumping gear when it comes to airway tools. I think adding equipment that works and makes sense is good. The majority of my tubes are are almost always placed traditionally with a curved blade (Mac 3 or 4) and a cuffed tube with a stylet. I love the Bougie and it gets a lot of use, often it’s the first thing I grab when I see a potential tough airway. I know space on our rigs and kits is limited and valuable but you’ll never see an OR say “what do we need to get rid of so we can have this instead?” When it comes to the airway box I think more tools to increase your chances of success is a good way to go.
 

RocketMedic

Earl of the Wheeled Chair
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I don’t think you should be dumping gear when it comes to airway tools. I think adding equipment that works and makes sense is good. The majority of my tubes are are almost always placed traditionally with a curved blade (Mac 3 or 4) and a cuffed tube with a stylet. I love the Bougie and it gets a lot of use, often it’s the first thing I grab when I see a potential tough airway. I know space on our rigs and kits is limited and valuable but you’ll never see an OR say “what do we need to get rid of so we can have this instead?” When it comes to the airway box I think more tools to increase your chances of success is a good way to go.
Strong disagreement. You know what you’re doing. The vast majority of us do not. Adding more tools to that doesn’t fix anything and introduces interesting new ways to fail,
 

NPO

Forum Deputy Chief
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Removing stylets from our airway bags because all of our tubes come preload of a stylets, and we use the king vision which is incompatible with stylets. They are just one more thing to get in the way and cause confusion during a stressful situation. We still have them in our tubes if we need them, and we have bougies.
 

RocketMedic

Earl of the Wheeled Chair
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Removing stylets from our airway bags because all of our tubes come preload of a stylets, and we use the king vision which is incompatible with stylets. They are just one more thing to get in the way and cause confusion during a stressful situation. We still have them in our tubes if we need them, and we have bougies.
I preload my Kingvision with a tube and bougie. If I don’t need the Bougie, I just advance the tube as normal. If I do, the tube forms a good guide for the bougie in spite of the hyperacute angle of the Kv blade. Combined with good suctioning and the Wilco Way, I’m pretty comfy in intubations.

With that being said, I haven’t DL intubated a real person in a year.
 

NPO

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Yep. Same. I also do it the WilCo way and I can honestly say I haven't missed a first attempt in I don't know how long. With all of the tools, techniques and training we have, we have made intubating way easier than it used to be.

That said, I did recently have a patient I knew needed to be intubated by a doctor, in an ER, and with support staff and not by me bouncing down the road. So I guess you could claim confirmation bias because I didn't tube the hard one?

I did need to do a DL recently, first in 2 years. I was surprised how easy the transition was. Muscle memory...
 

RocketMedic

Earl of the Wheeled Chair
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Yep. Same. I also do it the WilCo way and I can honestly say I haven't missed a first attempt in I don't know how long. With all of the tools, techniques and training we have, we have made intubating way easier than it used to be.

That said, I did recently have a patient I knew needed to be intubated by a doctor, in an ER, and with support staff and not by me bouncing down the road. So I guess you could claim confirmation bias because I didn't tube the hard one?

I did need to do a DL recently, first in 2 years. I was surprised how easy the transition was. Muscle memory...
Nothing wrong with delaying at all. Walls is pretty clear about that- don’t do it if you aren’t confident of success and you can maintain via alternative measures.
 

NPO

Forum Deputy Chief
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Nothing wrong with delaying at all. Walls is pretty clear about that- don’t do it if you aren’t confident of success and you can maintain via alternative measures.
This particular one was a gentalman, lethargic, shocky and in and out of consciousness. He was spewing copious amounts of blood from his mouth. My first thought was esophageal varicies. A quick history from his wife and I learned he had esophageal cancer, and it appeared that a tumor had begun bleeding.

Not knowing what his anatomy was going to be like, I wasn't confident paralysing him and he was maintaining his airway. So a quick ride to the ER was what he got.
 

FiremanMike

EMS Coordinator
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I don’t think you should be dumping gear when it comes to airway tools. I think adding equipment that works and makes sense is good. The majority of my tubes are are almost always placed traditionally with a curved blade (Mac 3 or 4) and a cuffed tube with a stylet. I love the Bougie and it gets a lot of use, often it’s the first thing I grab when I see a potential tough airway. I know space on our rigs and kits is limited and valuable but you’ll never see an OR say “what do we need to get rid of so we can have this instead?” When it comes to the airway box I think more tools to increase your chances of success is a good way to go.
The bougie is just better than a stylet. I pulled the stats at my department for the last 3 years and found (over the 3 year query) an average of 3 intubations, with an outlier of 11, a handful in the 4-6 range, and a mode of 1, meaning the majority of my folks have only intimated 1 time in 3 years (yes, I know, but that’s another topic entirely).

In those intubation attempts, the majority of the time, folks were using the king vision, which means traditional intubation is almost never done here. When it’s done, it needs to be done with the tool proven to have a better first pass success rate.

Not attacking you - but I did find it curious that you grab the bougie first when you “know” it’s going to be a difficult airway. Personally I treat and teach to expect every airway to be a disaster and then you can be pleasantly surprised when it’s easy..
 

GMCmedic

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I consider myself to be average to below average while intubatingwith tradional DL and stylette. I had 100% first pass success last year with DL and bougie on 7 intubations. September to now using the Mcgrath with 50/50 stylette/bougie im sitting at 90% on 10 intubations (the one miss i never attempted to pass a tube, cruddy anatomy).

Anecdotal, but bougie and VL are full of win.
 

StCEMT

Forum Deputy Chief
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My only thing with the KV is that it took me a lot of practice to get used to how it's different. I liked it alright enough, but I didn't find it to be as intuitive. However, I can't argue with results and I did eventually get the hang of it. I'd like to use it on a live intubation some day to see how I feel about it when actually put to use.
 

NPO

Forum Deputy Chief
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My only thing with the KV is that it took me a lot of practice to get used to how it's different. I liked it alright enough, but I didn't find it to be as intuitive. However, I can't argue with results and I did eventually get the hang of it. I'd like to use it on a live intubation some day to see how I feel about it when actually put to use.
Look up the WilCo in service on it. It changes everything.
 

ghost02

CA Kern Paramedic
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Look up the WilCo in service on it. It changes everything.
Thanks for suggesting that, I've actually never seen it and it was an eye opener. I'm willing to bet that there would be no need to remove intubation should this become standard practice. As per normal though, it's a choice between improvement, which is costly and requires effort, verses removal.
 

NPO

Forum Deputy Chief
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Why VL isn't standard of care is beyond me. It should be. There is no excuse.
 

NPO

Forum Deputy Chief
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It costs money my friend. Hell I want IV zofran and the auto tamponade IVs.
Again, not a valid excuse. They aren't THAT expensive anymore. Some things we need to work out the money.
 

ghost02

CA Kern Paramedic
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Again, not a valid excuse. They aren't THAT expensive anymore. Some things we need to work out the money.
I don't disagree. You've galvanized me to try and work this out actually. If there is one thing that I feel its worth fighting for it is this, and complaining about it isnt going to get me anywhere.
 

DesertMedic66

Forum Troll
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Again, not a valid excuse. They aren't THAT expensive anymore. Some things we need to work out the money.
It may not be a valid excuse but when you work for a private company that mainly focuses on profitability then any increased cost is not good. Why pay for VL when the equipment for DL is much cheaper. Until areas start mandating VL there are a lot of companies that will not switch.
 

StCEMT

Forum Deputy Chief
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Look up the WilCo in service on it. It changes everything.
I actually have watched all the stuff on it. But seeing something done and doing it are very different, especially when some finesse is involved. I was able to get it, just not quite as quickly as McGraths and similar devices.

Although some of the concepts seem pretty universal whether or not it is a track system or not.
 

KingCountyMedic

Forum Lieutenant
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The bougie is just better than a stylet. I pulled the stats at my department for the last 3 years and found (over the 3 year query) an average of 3 intubations, with an outlier of 11, a handful in the 4-6 range, and a mode of 1, meaning the majority of my folks have only intimated 1 time in 3 years (yes, I know, but that’s another topic entirely).

In those intubation attempts, the majority of the time, folks were using the king vision, which means traditional intubation is almost never done here. When it’s done, it needs to be done with the tool proven to have a better first pass success rate.

Not attacking you - but I did find it curious that you grab the bougie first when you “know” it’s going to be a difficult airway. Personally I treat and teach to expect every airway to be a disaster and then you can be pleasantly surprised when it’s easy..
No worries bro 🙂

Just different systems, our folks get 2-3 tubes a shift on average.
 
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