DO you video? Emergence of video assisted laryngoscopy in the field.

[NUEMT]

http://www.emsworld.com/news/12182007/ga-agency-adds-video-laryngoscopes-to-ambulances

Lots of agencies adding this to the toolbox. I myself have used it a few times and like the concept but I think it is important to realize that it is a new piece of equipment with its own unique sets of skills and challenges. Many of the fire medics I have come into contact with assume that it is automatically and easier way to get the tube and thus must not need to be practiced. I demonstrated some dummy head insertions and in 30 mins we were able to figure out a couple techniques to assure proper operation.

I have also heard of agencies totally stripping the rigs of the standard blades and handles in favor of these. I cannot agree with stripping a tool off a rig that still has viable application. The video laryngoscopes are for that sole purpose. I have seen no evidence of effectiveness in uses in conjunction with Mcgills in choking pts.

New technology is fun, and lord knows I love me a gadget, but we should be smart in our steps forward on this glacier.

 

[Gurby]

Just watched this video yesterday. John Hinds says video laryngoscopy should not replace direct prehospitally:

 

[NUEMT]

Hinds was a beast. Just an epic practitioner. His talk on cases from the races is just fabulous.

RIP John.

EMS folks who do not know of John Hinds, do yourself a favor and read up on this guy.

 

[chaz90]

Yes, we utilize video laryngoscopy using the KingVision for most of our intubations. We haven't replaced any of our direct laryngoscopy equipment with the KingVision, but it serves as a valuable adjunct to it and improves our first pass intubation success rate. Our agency prefers it for first line use over DL, but if there's a reason to use DL instead (wet airway, small mouth, concomitant suctioning, or provider preference in reality) it is considered perfectly acceptable.

I'm certain it's harder to adjust for providers who have been intubating using standard DL for 25 years, but as a fairly young medic who is comfortable with technology and video screens anyway, I think they are an outstanding addition to our toolkit. There is a learning curve technique wise, and if you don't understand or recognize the different techniques or goals of VL using your specific device, you're setting yourself up for failure. It took me several real intubations to become even passably comfortable with the KingVision, but at this point I've used it probably 15-20 times and absolutely love it. There is a risk of losing some of your DL skillset since it is so different and we're using it rarely, and I don't know a good solution for that. I've only used DL twice in the past year, and one was on a kid. I try to keep that in the back of my head, and if I need to go to the OR as a refresher, I'll do that.

 

[NUEMT]

Yes, we utilize video laryngoscopy using the KingVision for most of our intubations. We haven't replaced any of our direct laryngoscopy equipment with the KingVision, but it serves as a valuable adjunct to it and improves our first pass intubation success rate. Our agency prefers it for first line use over DL, but if there's a reason to use DL instead (wet airway, small mouth, concomitant suctioning, or provider preference in reality) it is considered perfectly acceptable.

I'm certain it's harder to adjust for providers who have been intubating using standard DL for 25 years, but as a fairly young medic who is comfortable with technology and video screens anyway, I think they are an outstanding addition to our toolkit. There is a learning curve technique wise, and if you don't understand or recognize the different techniques or goals of VL using your specific device, you're setting yourself up for failure. It took me several real intubations to become even passably comfortable with the KingVision, but at this point I've used it probably 15-20 times and absolutely love it. There is a risk of losing some of your DL skillset since it is so different and we're using it rarely, and I don't know a good solution for that. I've only used DL twice in the past year, and one was on a kid. I try to keep that in the back of my head, and if I need to go to the OR as a refresher, I'll do that.

Good plan. Does your area provide access to surgery for skill practice on intubation?

 

[chaz90]

Good plan. Does your area provide access to surgery for skill practice on intubation?

Yes. We have an agreement in place with a local hospital that allows us access to their OR and anesthesia providers. New hires undergo intubation practice along with existing employees if they don't have enough field intubations for a year or go below the required success rate. We're very fortunate in that regard.

Really, I should clarify that the anesthesia providers emphasize that we're there to practice the entire airway management continuum, not just the intubation itself. Tips and practice utilizing a mask seal and manual ventilations under their expert guidance have been just as or more valuable than the intubations I've had there.

 

[NUEMT]

Agreed. Surgery intubations are particularly controlled and sterile as adversity goes. The variable being the actual patient and whether or not its a difficult airway.

We have an ECT rotation here that lets us focus only on BVM and airway continuum which I actually really enjoyed. Anesthesiologist administers sedation and we bag while Psych administers treatment.

 

[Carlos Danger]

http://www.emsworld.com/news/12182007/ga-agency-adds-video-laryngoscopes-to-ambulances

Lots of agencies adding this to the toolbox. I myself have used it a few times and like the concept but I think it is important to realize that it is a new piece of equipment with its own unique sets of skills and challenges. Many of the fire medics I have come into contact with assume that it is automatically and easier way to get the tube and thus must not need to be practiced. I demonstrated some dummy head insertions and in 30 mins we were able to figure out a couple techniques to assure proper operation.

I wouldn't go so far as to say that video laryngoscopy doesn't require any training or practice, but in all honesty, that's not too far off. Numerous studies have shown that people develop skill with it way faster than they do with direct laryngoscopy.

I have also heard of agencies totally stripping the rigs of the standard blades and handles in favor of these. I cannot agree with stripping a tool off a rig that still has viable application.

I think we probably aren't too far from a time when VL is considered the standard of care for every intubation. Of course like most everything else, it will probably take EMS years longer than the rest of healthcare to adopt the standard practice.

I've read commentary for a few years already about how "occasional intubators" should only use VL, and there are residency programs where the physicians-in-training use VL pretty much exclusively.

 

[FiremanMike]

I spent a lot of time getting really comfortable with DL + Bougie intubations at my primary job, because my secondary job (flight) didn't have VL at the time. When I quit my secondary job, I decided to switch to VL (via King Vision) at my primary job and almost felt like it was cheating.

I am in complete agreement with Remi's last statement.. Occasional intubators (I would personally define that as 6 or less per year) should focus solely on VL and should likely go directly to a supraglottic in the event of a VL failure.

 

[TransportJockey]

We use a King Vision for 90 percent of our first passes. And it is mandated for 100 percent of smr intubations. We also still practice dl and i use a bougie with every attempt.

 

[SpecialK]

I've had a fiddle with VL once or twice, it's quite cool.

I can certainly see the advantages however, to provide it to even our RSI ICPs would cost tens of thousands of dollars we simply don't have so it will not be making an appearance on ground ambulances anytime soon. I can foresee it coming, however only for our RSI ICPs, many patients whom would have once traditionally been intubated (without RSI) now simply get an LMA.

Our Doctor/ICP staffed HEMS has VL and they can respond by road as well if required.

 

[Tigger]

We are hoping to equip our ambulances with units via grant funding. I am struggling to get by-in from many of our more experienced providers, so I'm a little worried they aren't going to be used much. Our paramedics are probably intubating 8-10 patients a year, so not a ton. For better or for worse though, 100% of the patients that our paramedics chose to intubate last year were successfully intubated and that number was 98% the year before. There have been no unrecognized esophageal intubations in over five years. As such, many think we just don't need them, which is of course a bit silly. Those "statistics" do not count for potentially deleterious complications nor do we know that we can maintain that rate.

But change is hard I guess. At least the McGrath units that we are trialling can allegedly be used with a technique similar to that of DL Mac blades. But then of course we have paramedics that think Mac blades are for weak paramedics sooooo.

Price wise with supplies we are looking at a per unit cost of around 4k.

 

[STXmedic]

We carry the Pentax, which I'm not all that fond of personally. I don't have anything against VL, but the Pentax is too bulky for my liking. I greatly preferred the McGrath when we were trialing products.

Its entirely up to our disagression as yo when to use it. The only time it's mandated to be out is during RSI. I probably use it close to 50% of the time. It's definitely saved my *** on one particularly difficult intubation.

 

[aquabear]

I'm just going to leave this journal article right here....

EMS Intubation Improves with King Vision Video Laryngoscopy.

http://www.tandfonline.com/doi/pdf/10.3109/10903127.2015.1005259

The system I work for uses the King Vision with channeled blade for all intubations and an ET tube is our first line airway with the i-gel only used as a rescue airway. We still have DL for FBAOs and meconium suctioning so I try to keep both skills up.

 

[kev54]

Just watched this video yesterday. John Hinds says video laryngoscopy should not replace direct prehospitally:

I can second that.

 

[StCEMT]

I'm certain it's harder to adjust for providers who have been intubating using standard DL for 25 years, but as a fairly young medic who is comfortable with technology and video screens anyway, I think they are an outstanding addition to our toolkit.

I can confirm that, I have learned the standard way and with the McGrath pretty much all at the same time. I can do both if I need to, but as far as how I position myself, I am much more comfortable with the McGrath. That being said, I've yet to have a difficult intubation, so I can't really comment on how much better the video may be.

 

[Carlos Danger]

Just watched this video yesterday. John Hinds says video laryngoscopy should not replace direct prehospitally:

Meh, I think he makes a really weak case for not using VL in the field. His entire argument is based on the premise that VL doesn't improve success rates or outcomes, and for a physician trained in both anesthesia and EM, it may not. But we are not all John Hinds......we know that for most of us, it does make a difference.

Also, the argument that VL doesn't work when wet or when really bright out is just silly.

 

[CANMAN]

HEMS- We have a CMAC on every aircraft and it's the preferred method with recording if appropriate. That being said we only carry the CMAC 3 & 4 blade. So if I am tubing a difficult airway or obese person I will likely use DL and a miller. Same for peds.

911 job- We have a King vision, and I am not a fan. We don't have to use it at all, and I typically don't.

All our quarterly O.R. tubes have to be traditional DL

I think stripping a rig of regular intubation equipment is ridiculous. Unless you're using a CMAC, what are you using when the device fails?

 

[Carlos Danger]

I think stripping a rig of regular intubation equipment is ridiculous. Unless you're using a CMAC, what are you using when the device fails?

An LMA?

 

[CANMAN]

An LMA?