How did you learn to intubate?

[NYMedic828]

Woah. That's pretty darn cool. The medic I was working with today lay prone to tube somebody –:censored:hadn't seen that before, and that was pretty boss, so I can't imagine how awesome upside down intubation would be!

Speaking as a BLS fellow, how do you want us BLS'ers to help when you're tubing a patient, beyond pre-oxygenation? Sellick's?

Prone is a pretty common occurrence all over the place. As far as upside down goes we strapped a manikin to the bottom of a table its not as cool as it sounds on a dummy lol.

We usually put the patient on the floor immediately if it hasn't been done already before we get there. I usually get on my knees and hope to have a decent enough view before I attempt to kiss the floor of a project apartment.

As far as helping, continue CPR to the best of your abilities because that is all that really matters.

 

[triemal04]

:unsure:

My program was pretty in depth on intubation. Our pulmonology portion was taught by our medical director which was nice of him to come in for. (very well respected EM doc. Hardass though)

We did some other stuff like intubating patients "tomahawk" style in a car or upside down and whatnot but obviously haven't done that on too many live ones. -_-

Think I did 5 or 6 tubes in the OR? Our success rates on my unit seem to be around 90% if i had to guess a number. I can't vouch for the rest of NYC but we do a few arrests a month per shift.

So you think that the average paramedic is truly proficient at intubating? (notice, that like when I said "most" in my previous post I said "average" here) I'm not pointing any fingers at anybody so don't get upset, but, like it or not, taken as a whole EMS sucks at intubation. Even ignoring studies done in southern Cali or Florida where everybody and their brother is a paramedic, intubation is not something that most (that word again) paramedics can say they are truly proficient at. Yes, there are notable exceptions to that.

You say your service does a few arrests a month. How many times a month is your average paramedic intubating? How often are they getting success on the first pass? How often are they able to intubate with absolutely zero interruption in compression? How often is there ANY trauma inflicted during the attempt? (that means even a small, small smear of blood on the blade) There's more to ask than that, but you get the picture.

You say you had an EM doc teach you pulmonology...great. No sarcasm, I mean that. How many schools do you think have a doctor taking active involvement in teaching? How much went into specifically teaching you how to intubate? How long did you spend in the OR to initially learn? How often are you intubating each year? How often are you having to use an adjunct of any kind to successfuly intubate? And the other questions I asked above. Like I said, there are plenty of exceptions to what I've said, but on average most paramedics don't intubate very often, and, given that many schools don't send students to the OR, never learned very well in the first place. Hell, one prolific poster here recently said something along the lines of it being several monthes since their last tube...nationally, do you think that's uncommon?

I'm not saying any of this to get into a pissing match, just to be honest. Really, it's a damn shame, especially since there is starting to be more info that indicates that intubation, if done properly by a competant provider is beneficial.

I'm also not saying any of this to mean that I'm the :censored::censored::censored::censored: when it comes to intubation. I've got to a acceptable level of skill only, and hopefully will be able to maintain that throughout my career.

 

[Handsome Robb]

Take my advice with a grain of salt. I've intubated one live patient and that was a 19 month old cardiac arrest and that was sitting in the airway chair in the box so I was able to really set myself up how I wanted to and had excellent lighting.

***Set yourself up for success.***

Get everything you will or might need all set up organized. Position the patient, pad behind their shoulders and extend their neck. Once you've got that done get your scope and do it just like you've been taught. Once you visualize the cords *don't* take your eyes off them, ask the person next to you to hand you the tube you want while you keep your eyes on the cords. Watch the tube pass, listen to confirm, get the capnography going, secure the tube, re-check your placement, pass bagging off, do the funky chicken dance.

The last step is the key step.

 

[DrParasite]

If you have some adventurous friends you can always practice the technique on a real person. Just find someone who lacks a gag reflex

I knew a couple of girls in college like this....

 

[Sasha]

Take my advice with a grain of salt. I've intubated one live patient and that was a 19 month old cardiac arrest and that was sitting in the airway chair in the box so I was able to really set myself up how I wanted to and had excellent lighting.

***Set yourself up for success.***

Get everything you will or might need all set up organized. Position the patient, pad behind their shoulders and extend their neck. Once you've got that done get your scope and do it just like you've been taught. Once you visualize the cords *don't* take your eyes off them, ask the person next to you to hand you the tube you want while you keep your eyes on the cords. Watch the tube pass, listen to confirm, get the capnography going, secure the tube, re-check your placement, pass bagging off, do the funky chicken dance.

The last step is the key step.

I prefer to walk it out after. The funky chicken dance is old AHA standards.

Although i have read some of the more advanced system do the Cupid shuffle afterwards.

 

[NomadicMedic]

I knew I needed to get the Cupid Shuffle added to our protocols!

Ours still say, "...consider the Macarena"

 

[Sasha]

I knew I needed to get the Cupid Shuffle added to our protocols!

Ours still say, "...consider the Macarena"

Holy ancient protocols Batman!

 

[Veneficus]

Prone is a pretty common occurrence all over the place. As far as upside down goes we strapped a manikin to the bottom of a table its not as cool as it sounds on a dummy lol.

We usually put the patient on the floor immediately if it hasn't been done already before we get there. I usually get on my knees and hope to have a decent enough view before I attempt to kiss the floor of a project apartment.

As far as helping, continue CPR to the best of your abilities because that is all that really matters.

I used to play all those games of contorted positions, etc. Then a much experienced paramedic gave me the secret...

Just bag them until you put them on the stretcher, then either raise the head 30 degrees or the stretcher to the level you like.

If you end up not transporting, just put them back on the floor.

Work smarter not harder.

 

[EpiEMS]

Really? If the person is on the floor or ground I usually lie prone to intubate them. It is much easier than kneeling. I once had to lie under a bed to tube a guy because the room was too small for me to lay anywhere else and there was no where else to move him.

First live tube I've seen outside of an OR, so anything qualified as cool

As far as helping, continue CPR to the best of your abilities because that is all that really matters.

Yeah, that makes sense. I just want to be sure I'm being as useful to ALS providers as I can possibly be.

 

[NYMedic828]

I used to play all those games of contorted positions, etc. Then a much experienced paramedic gave me the secret...

Just bag them until you put them on the stretcher, then either raise the head 30 degrees or the stretcher to the level you like.

If you end up not transporting, just put them back on the floor.

Work smarter not harder.

Never thought about that, but we usually don't have stretcher access to the room and most times we don't end up transporting unless we get a pulse back.

We usually need to use the bedsheets or a scoop to carry the patient to the hallway and on the stretcher.

 

[Aidey]

^^^ Exactly. The call where I was under the bed was on the third floor of a house. No way in heck we were going to carry him down unless we got a pulse back.

 

[BLS Systems Limited]

As a Respiratory Therapist, I found success by placing a towel under the head, raising it slightly. Of course you wouldn't do this for head/neck trauma, but it works far, far better than tilting the head. For the older ones in the crowd, it was called the "morning sniff" position, or one that would resemble a Thurston Howell III jaw jut. Slide the scope in until the tip hits the valecula and have the handle pointing towards the join between the wall and the ceiling. Lift in the direction of the handle and definitely don't tilt backwards. When done properly, physics wins as I have seen very petite anaesthesiologists tube very large heads.

 

[NomadicMedic]

It's a simple matter of aligning the three airway axes. Between padding and manual manipulation you can almost always see something.

 

[Christopher]

Slide the scope in until the tip hits the valecula...

I think this is the step that both novice and seasoned intubators struggle with, mostly because while they know what it is and where it is, they aren't proficient at getting there consistently.

The only way to do this consistently is to have a methodical approach, based on identification of the epiglottis and arytenoids (posterior cartilage).

1. Insert the blade midline and walk down the tongue, identifying structures, until the epiglottis comes into view
2. Slide the blade (Mac) to the right of midline to place the tongue on the left hand side of the flange (a Miller blade requires a different technique)
3. Once the epiglottis is visible, advance the tip of the blade forward until the epiglottis lifts itself from the posterior pharyngeal wall
4. At this point, if the epiglottis is not mobile you may need to provide external laryngeal manipulation in order to seat the tip in the valecula
5. Once the epiglottis is mobile--with respect to the tip of the blade--you lift the handle outward until you can identify the arytenoids

Identification of the epiglottis and arytenoids are key, as these provide the inferior and superior boundaries of the glottic opening.

 

[Veneficus]

^^^ Exactly. The call where I was under the bed was on the third floor of a house. No way in heck we were going to carry him down unless we got a pulse back.

Not being smart, but to the best of my memory, not once has intubation made a difference on whether or not a pulse was regained.

Just figured I would pass on the wisdom given to me by somebody who saved me one or two uniforms, strained muscles, and the station from more than a few roach infestations.

 

[Aidey]

Unfortunately some of the docs around here are hesitant to let you call it unless the pt has been intubated. Don't ask me why. It is a pain in the arse when you have to transport just because the pt isn't tubed.

 

[Veneficus]

Unfortunately some of the docs around here are hesitant to let you call it unless the pt has been intubated. Don't ask me why. It is a pain in the arse when you have to transport just because the pt isn't tubed.

Yea, that is rather common everywhere.

I think somebody at some time thought it was the only way to prove that the patient didn't have an airway obstruction and/or nonreversible hypoxia.

Unfortunately it probably came out about the time as many other EMS practices and is forever enshrined in undisputable practice.

I wonder how anyone was pronounced dead prior to the invention of the battery powered laryngoscope?

"The patient is not dead until digitally intubated or surgically criced."

 

[DrParasite]

so tube them. why not? unless they are obviously dead on onset, what is the downside to intubating a person in cardiac arrest?

people always say paramedics don't get enough intubations in order to maintain proficiency. it's a clinical skill, one that has legitimate use in cardiac arrest patients. and if the doc wants him pronounced, than just leave him on scene.

on an unrelated note, I once removed a patient (who was an intubated cardiac arrest) using the bedsheet, and carried him out about 6 feet to the stretcher waiting outside. About 2 hours later, after the call was completed, I was called into the boss's office (paramedic who jumped the call because, well, he could), who said to never do that, since it can dislodge the tube, and to always use a reeves, backboard or scoop to maintain a neutral position.

 

[Aidey]

We are almost required to put a c-collar on all intubated patients to prevent excessive neck movement. It isn't actually required, but it is so strongly recommended that if you have a pattern of not doing it you will get talked to.

 

[medicsb]

so tube them. why not? unless they are obviously dead on onset, what is the downside to intubating a person in cardiac arrest?

people always say paramedics don't get enough intubations in order to maintain proficiency. it's a clinical skill, one that has legitimate use in cardiac arrest patients. and if the doc wants him pronounced, than just leave him on scene.
QUOTE]

ETI interrupts chest compressions and interruption is associated with poor outcomes. Most medics don't intubate often and can be assumed to be not proficient, thus the time it would take them to intubate is potentially of greater detriment than any potential benefit from having an ET tube in place. This is why many places now are only using supraglottic airways.

However, in my opinion, if the medic is proficient enough to either intubate with compressions in progress or with only a brief interuption, coordinated with a rhythm or pulse check, then I would be in favor of it.