How did you learn to intubate?

[newEMT]

So, I'm not a paramedic. I'm a 3rd year med student who just started my anesthesia rotation. Up to this point, I've been intubating plastic heads with no body. Today, they let me try to intubate a real patient.

I started by opening their mouth with the scissor technique. I slid the largynoscope in, but I couldn't get past the tip of their tongue because the handle was hitting their chest. I didn't want to crank back and break all of their teeth. I stood there thinking for a second because this was the first time my "patient" actually had a torso. In hindsight, I should have just extended their head more. The resident didn't offer any pointers. Instead, she took over and did the intubation. She told me just to watch. Then, she spent 10 minutes telling me that it's not important for me to learn how to intubate. She told me just to watch for now on. So, there went my first and last chance to intubate.

My question is how do paramedics learn to intubate and do you have any pointers for me? I probably won't get to intubate again until I'm an emergency medicine resident. But, I still want to know.

 

[Aidey]

Don't pull back, push up away from you. If the handle was on their chest your positioning was WAY off. A good starting point is for the angle of the handle to be in line with their nose.

And we learn to intubate the same way. With a plastic head and then on real people. Once you get the technique down it isn't that difficult.

If you have some adventurous friends you can always practice the technique on a real person. Just find someone who lacks a gag reflex or use some Lido throat spray. You obviously can't actually intubate them, but you can get familiar with visualizing the cords.

 

[terrible one]

YouTube might help show you some pointers. The handle should never come close to touching the chest, not sure how you pulled that off?

 

[newEMT]

I think their head was too flexed and I couldn't even get the blade past the tip of their tongue because the handle was on their chest. Similar to pic below.

http://utenti.unife.it/giampaolo.garani/Trauma/Trauma-Ped/Fig-caso/intubate.jpg

 

[Aidey]

Flexion may have been an issue, but once you slide the blade in using that position you have to push up and away if you want to see anything. Not pull back.

 

[newEMT]

Flexion may have been an issue, but once you slide the blade in using that position you have to push up and away if you want to see anything. Not pull back.

Yeah, I never pulled back. I was very conscious of the teeth. I never got past the tip of the tongue. I just stopped because I didn't know what to do. And, they immediately took it out of my hands and did it for me. I didn't mind that, but being told to "watch" for the rest of the rotation because I couldn't do it on my first attempt sucks. It's not like I injured the patient :sad:

 

[Aidey]

Anesthesiologists are a difficult group I've found. When I did my OR time to practice intubating only one of the 5 or 6 supervising us was truly helpful. One insisted we know all the doses for all the anesthesia drugs before we could intubate. Not just the drugs commonly used in by paramedics, all of them.

Your best bet may be to watch YouTube videos, and see if you can do another shift and try again. The ED is not the best environment to learn in because everything tends to be rushed and hectic.

Some of the ED docs here let us intubate if they know us (we need a minimum number of tubes a year for our certs). Excluding the patients that are dead, a lot of the time the pt is getting Intubated prior to going for a CT or MRI because they are a potential CVA or head injury. The docs want them tubed and gone ASAP. With the impending respiratory failure patients things aren't quite as rushed, but then you have to worry about RT taking over.

 

[NYMedic828]

When I went for my first incubation on a real patient I made the same mistake of being too gentle.

Extend their neck first. Be gentle, but make sure you actually extend it. You aren't going to break their neck it is meant to bend.

You really need to scissor their mouth open all the way. Your fingers will be spread pretty far apart if you extended the jaw far enough.

Insert the blade sort of riding on the tongue until you feel it is in the velecula. (this takes a couple times to get a feel for)

At that point, lift up. Don't change the angle of your blade.

The best thing about being in the hospital, is you can get your head at the level of the patient to get a great view. On a stretcher or a floor in a house you don't get this privilege and sometimes may not be able tell for sure if the tube went through the cords until you confirm it.


Side note, I found almost every anesthesiologist where I did my rotations to be stuck up :censored::censored::censored::censored::censored::censored::censored::censored:s. None of them were American either so I could barely understand them. The nicest person there was the CRNA who I did my best to cling to and ask questions.

 

[MSDeltaFlt]

I learned as a staff respiratory therapist that took detailed in-service and got checked off by nurse anesthetist in surgery. Very hands on and patient CRNA who had to deal with a nervous kid who was scared to death.

 

[NomadicMedic]

I learned by doing HUNDREDS on a series of plastic heads.

Then I went to the OR and did a bunch with a CRNA and an Anesthesiologist. I learned a LOT from both of them. They enjoyed teaching and let me have lots of time to learn, ask questions and practice. From what I understand, that's very rare in the OR and I feel truly lucky to have had such a positive experience.

I also take advanced airway labs whenever possible. The ShockTrauma cadaver lab is excellent. I visit the OR at least twice a year and spend a day with the CRNAs dropping tubes and LMAs.

And I get more than a few in the field. <_<

And I’m still only baseline competent. I feel that every tube is a learning experience and I know I'll never be nonchalant about intubation.

 

[NYMedic828]

On a side note, we have an anesthesiologist who just joined at my volly house to be an EMT. He is worthless.

He won't talk to patients on alarms and has no medical advice to share. He said he isn't comfortable talking to patients who are awake. He barely speaks English as well.

I was excited to hear about his membership until I met him. Very disappointing.

 

[EpiEMS]

He said he isn't comfortable talking to patients who are awake.

h34r:

 

[jjesusfreak01]

h34r:

Hey, could be worse...they could have gotten a pathologist...you know where i'm going with that.

 

[EpiEMS]

Hey, could be worse...they could have gotten a pathologist...you know where i'm going with that.

Haha! Or a colorectal surgeon..."I can only talk to patients with my finger in their arse."

 

[ah2388]

It sounds as though you're kind of down about this experience.

The skill will come, dont sweat it.

I'd suggest giving it another shot, possibly with a CRNA or different resident.

 

[triemal04]

I started by opening their mouth with the scissor technique. I slid the largynoscope in, but I couldn't get past the tip of their tongue because the handle was hitting their chest. I didn't want to crank back and break all of their teeth. I stood there thinking for a second because this was the first time my "patient" actually had a torso. In hindsight, I should have just extended their head more. The resident didn't offer any pointers. Instead, she took over and did the intubation. She told me just to watch. Then, she spent 10 minutes telling me that it's not important for me to learn how to intubate. She told me just to watch for now on. So, there went my first and last chance to intubate.

My question is how do paramedics learn to intubate and do you have any pointers for me? I probably won't get to intubate again until I'm an emergency medicine resident. But, I still want to know.

That'll sometimes happen. Usually due to poor positioning, but it can happen with obese patient's as well. Since this was in the OR I'm guessing there was either a doughnut under the head or some other type of padding to extend the head, so you probably just needed to flex the neck more. Not to much though, and remember it's head extension + neck flexion, not just one. It may not have helped in this situation, but once you have the blade (macintosh) mostly inserted you can put your right hand under the occiput and help manipulate the head. Does wonders for your view.

If you are shooting for a specialty where you will be expected to intubate patients, then you should try and get practise now. Next time you're there talk to the resident about how they intubate, why they do it like that, what makes it harder/easier, common problems, how to overcome them, common mistakes that are made and how to avoid them and the like. The vast majority of residents that I've met are willing to teach, if you show an interest, don't act like a ****, and approach them at the right time ie not in the middle of a :censored::censored::censored::censored:ty intubation or crashing patient.

To answer your last question, most paramedics don't learn how to intubate, not at anything approaching competancy anyway. It's a lot of the reason why the success rate is so dismal. (but not the only reason)

 

[Aidey]

This conversation reminds me of a code that was worked in one of the local hospitals. Code blue is called for a room on the general med/surg floor and the code team goes running. The NEPHROLOGIST visiting a patient next door had the patient intubated by the time the code team doc got there. He said that he was used to sticking tubes into little holes and it wasn't all that different.:blink:

 

[NYMedic828]

To answer your last question, most paramedics don't learn how to intubate, not at anything approaching competancy anyway. It's a lot of the reason why the success rate is so dismal. (but not the only reason)

: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.

 

[EpiEMS]

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. -_-

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?

 

[Aidey]

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.