Curved vs. Straight blades

[NomadicMedic]

This was a *******ized version, fully unauthorized I'm sure, that did use stuff from Wall's book (and his algorithms) and was taught by a couple of medics and a CRNA, who used to be a medic. I had the opportunity to take the real class a few years again and missed it due to scheduling. Everyone said it was very good.

I took SLAM, street level airway management, and that was pretty good. Lots of little tips and tricks to stack the deck in your favor. The guy that taught it was all about war stories, which was a little offputting.

 

[TXpeds16]

Like others have said, it is completely provider preference. While working pre-hospital I preferred a mac 3. Nowadays I work for a pediatric transport team and in most cases a miller 2 does the trick; however, with larger pediatrics and adults I still use a mac 3.

 

[SeeNoMore]

Most providers I know rarely use a straight blade on an adult. I generally use a Mac 4 w/ a bougie on every intubation that I don't choose to use VL (other than peds of course.)

 

[StCEMT]

We were told general rule of thumb was Mac for adults and Miller for peds and then to experiment and see what we like. I haven't intubated any crappy airways yet, but I have so far personally preferred the 3 Miller. Always felt like it took less effort to get the epiglottis out of the way.

 

[VentMonkey]

My most recent RSI actually had surprisingly large teeth, and a large tongue for what looked to be an otherwise normal airway; slightly anterior also.

I stuck it out with my Mac 4, though in retrospect I suppose I could have downgraded to the Mac 3 for easier manipulation.

Either way it turned out fine, and I am happy to report all teeth were in tact, and remained un-chipped and accounted for in the end.

The kiwi grip bougie trick was my takeaway here, as I found once I ever so gently swept the tongue out of the way,and pulled up and towards the feet, I was able to get a good grade 3 view allowing for a fairly easy pass.

My takeaway here is that even though the airway had the potential for difficulty, proper set up (suction ready, Mac 3 set up, tube tamer ready, ETCO2 ready, etc.), and preparation seems much more pertinent than the blade type itself, aside from peds that is; certainly "da bey-bez" get the Miller blade.

 

[SeeNoMore]

If you are competent, educated and prepared you should be able to calmly transition to a new blade or approach if there is a need for it. I think the problems arise when providers start missing , panicking and just grabbing devices or new blades without a plan. I think the best example of this is when medics can't get a view with DL and then reach for a VL device they never practice with and don't understand. Bad news.

 

[VentMonkey]

If you are competent, educated and prepared you should be able to calmly transition to a new blade or approach if there is a need for it. I think the problems arise when providers start missing , panicking and just grabbing devices or new blades without a plan. I think the best example of this is when medics can't get a view with DL and then reach for a VL device they never practice with and don't understand. Bad news.

Agreed. Even though "Fred the Head" is straightforward practice, I'll still give him a whirl with our VL when downtime permits at our base.

Simply being familiar with how to use whatever VL or back up device (let's not exclude proper SGA placement) it is you use is the key to a calm, cool, and collected approach.

I always find it ironic how the lazier providers typically bark the loudest, but are easily rattled. To me, preparation begins with something as simple as checking out your equipment at the beginning of EVERY SHIFT (ugh, how dare your employer expect you to do your job?!), and setting it up exactly how YOU want it does wonders for a calmed providers approach.

No real secret really, just don't be a lazy jackass.

Side note: any non-Wilco EMS paramedic using the KV as a VL, I highly recommend giving Dr. Jarvis' tutorial(s) a gander...

 

[Tigger]

In class we were taught to directly manipulate the epiglottis with a Miller and to place Macs in the vallecula, though you also have the option of pinning the epiglottis with it if you wanted to. I think it is easier to move the tongue out of the way with a Mac, so that is what I reach for. But really, it comes down to your preference. All the ED docs used Macs and all the anesthesiologists I did rotations with used curved blades if they weren't using VL for every tube. There was one who liked to switch off, but he seemed to like challenging himself and I found him slacklining in the park one day.

My regular partner and mentor is a mac person. But my captain, who I run a lot of calls with, will immediately question my use of a curved blade. "That blade is for [insert choice term for female anatomy]. It sucks. If they are anterior, you can't get the tube. Grandviews are also for [same term]. You will use a Miller, because that's what will bail you out." I think that is crap and try very hard to not let it effect me, but it is hard. The guy is a rather abrasive but exceptional paramedic. If I needed to be intubated, I want him to do it. But for me, I think the Mac 4 is easier. Which is the goal, make it as easy as possible. We do not have enough grandviews for our all our kits and they won't order more. I wrote a grant for McGraths, there is a huge amount of pushback to even carry them in the bags.

I do not care how I get the tube so long as I don't do damage and I get it done efficiently yet I get pressure to do things a certain way, which is absurd to me. I want to use a bougie on every tube as well, you can imagine how that is going...

 

[StCEMT]

I wrote a grant for McGraths, there is a huge amount of pushback to even carry them in the bags.

I do not care how I get the tube so long as I don't do damage and I get it done efficiently yet I get pressure to do things a certain way, which is absurd to me. I want to use a bougie on every tube as well, you can imagine how that is going...

Why is there pushback on the McGrath? My local medics have had them for a while and a few have said that they have had intubations (bloody airways etc) that it was really helpful with. Seems nice also if you are in a less than ideal position/environment...

Have you gotten the "it is a crutch" line about using a bougie? I didn't argue it in the OR, but in the field people can piss off. Makes no sense to argue against being proficient with a tool to help complete the task.

 

[VentMonkey]

In class we were taught to directly manipulate the epiglottis with a Miller and to place Macs in the vallecula, though you also have the option of pinning the epiglottis with it if you wanted to. I think it is easier to move the tongue out of the way with a Mac, so that is what I reach for. But really, it comes down to your preference. All the ED docs used Macs and all the anesthesiologists I did rotations with used curved blades if they weren't using VL for every tube. There was one who liked to switch off, but he seemed to like challenging himself and I found him slacklining in the park one day.

My regular partner and mentor is a mac person. But my captain, who I run a lot of calls with, will immediately question my use of a curved blade. "That blade is for [insert choice term for female anatomy]. It sucks. If they are anterior, you can't get the tube. Grandviews are also for [same term]. You will use a Miller, because that's what will bail you out." I think that is crap and try very hard to not let it effect me, but it is hard. The guy is a rather abrasive but exceptional paramedic. If I needed to be intubated, I want him to do it. But for me, I think the Mac 4 is easier. Which is the goal, make it as easy as possible. We do not have enough grandviews for our all our kits and they won't order more. I wrote a grant for McGraths, there is a huge amount of pushback to even carry them in the bags.

I do not care how I get the tube so long as I don't do damage and I get it done efficiently yet I get pressure to do things a certain way, which is absurd to me. I want to use a bougie on every tube as well, you can imagine how that is going...

Brother, fret not. As I would tell all my interns..."you will find YOUR groove." And when you do, you stick with what works for YOU.

I find it all ego, and hoopla when people argue over one vs. the other. It truly is what YOU are most comfortable with. Although I will say I find Bougies have worked wonders for first pass success rate for me.

Good luck, and once you find your groove, the skill itself is like any other "monkey skill", it's pieceing everything else around it that makes for a prudent clinician.

 

[jwk]

My tongue in cheek answer is that anyone can muscle a tube in with a straight blade, but it takes far more skill and finesse to use a curved blade.

I think straight blades are generally more traumatic, and most airway/dental injuries I see caused by others happens with straight blades.

The best blade to use is the one you have the most success with. I use a Mac 3 for 99% of by DL's.

Most people I see using a Miller 2 are using it like a curved blade anyway - it's frequently not long enough to lift the epiglottis
.

Curved blades work fine with infants if you practice with them - the idea that a straight blade is the only one to use for pedi cases is crap.

 

[Tigger]

Why is there pushback on the McGrath? My local medics have had them for a while and a few have said that they have had intubations (bloody airways etc) that it was really helpful with. Seems nice also if you are in a less than ideal position/environment...

Have you gotten the "it is a crutch" line about using a bougie? I didn't argue it in the OR, but in the field people can piss off. Makes no sense to argue against being proficient with a tool to help complete the task.

Oh yea. "So why did you think it was a difficult airway that needed a bougie?"

I didn't think it was a difficult airway. But I don't find out the hard way. Also, I can't see how the bougie is going to help in a disaster airway if I am not already comfortable using it. Therefore I want to use it all the time.

 

[SeeNoMore]

I just use the bougie 100 percent of the time. I figure if I treat every airway like its going to be difficult I'll be ahead of the game when it really is.

 

[Tigger]

I just use the bougie 100 percent of the time. I figure if I treat every airway like its going to be difficult I'll be ahead of the game when it really is.

That is my logic, I get a lot of weird looks.

 

[TransportJockey]

I just use the bougie 100 percent of the time. I figure if I treat every airway like its going to be difficult I'll be ahead of the game when it really is.

Thats my thought too. I get weird looks and annoy people for it

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[Handsome Robb]

Side note: any non-Wilco EMS paramedic using the KV as a VL, I highly recommend giving Dr. Jarvis' tutorial(s) a gander...

"Howdy y'all!"

I personally. Like the KV we've got a first pass success rate in the 90s. It would be even higher if having to back out to clean the camera because it got gunked didn't count as a miss.


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[NomadicMedic]

Funny, I use a bougie on 100% of my tubes and get the funny looks too. I was asked, "did you think that was going to be a tough tube?" Nope. But I use a bougie every time, because I'd rather stack the deck in my favor.

 

[akflightmedic]

Agreed. You have a tool which has proven it's usefulness time and again and is darn near or should be the standard, yet people who prefer to keep it as a "back up assist device" or let their pride/ego get in the way. Ummm, we have a human in front of us who needs an airway...if you provide one you are still a "hero".

The human condition confounds me repeatedly. Just like lift assists...yeh I could do 90% or more of the lifts on my own, but why should I when I have other tools/people there to lessen the risk? Ugh...

 

[EpiEMS]

Seems like the problem is as much cultural as it is anything else.
Love this convo, guys!

 

[Handsome Robb]

We use a bougie on every attempt, we'll sort of. We preload the ETT into the king vision then preload the bougie into the ETT however don't extend it past the tip of the ETT. If you can pass the tube without it great, if you need it it's right there and ready to go.


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