Intubation facts when performed on our own

[VentMedic]

I knew there was something else!! He also wouldn't allow a stylette. Again with the long explanations as to why you don't actually need a stylette.....

Part of the problem we have in EMS. It is called Cowboy medicine.. we need to leave the ego's at the door. Personally, I too forget about placing the styllet in prior, but feel like a fool when I do have to stop and then place one in. Any tool or device that can increase my success I am in favor of.

R/r 911

I had to learn to intubate without a stylet for Flight and specialty transport including NICU.

In L&D you are expected to be able to intubate the meconium babies quickly with at least two passes and a stylet can get in the way. You have to do this before that baby decides he/she wants to take that first big breath.

The point the doctor was probably trying to stress, especially in emergent situations, is that a stylet is not always necessary. I have seen too many paramedics and others (RTs, MDs, PAs, NPs) actually lose focus and go to pieces because some piece of equipment like a stylet is not available. I'm sure this Anesthesiologist has seen this happen many times while training all the different professionals. By introducing a new intubator to this actually can make them stronger in the long run.

If it is available, use it. If for some reason you don't have it, you should know that you can still accomplish the task if necessary.

 

[emtlady76877]

He wants us to be good enough that we can intubate with or without a stylette with a mac or a miller blade,because someday you might have a case where there is not a stylette available.

 

[MedicPrincess]

The point the doctor was probably trying to stress, especially in emergent situations, is that a stylet is not always necessary. I have seen too many paramedics and others (RTs, MDs, PAs, NPs) actually lose focus and go to pieces because some piece of equipment like a stylet is not available. I'm sure this Anesthesiologist has seen this happen many times while training all the different professionals. By introducing a new intubator to this actually can make them stronger in the long run.

If it is available, use it. If for some reason you don't have it, you should know that you can still accomplish the task if necessary.

Exactly!! As an EMT, I watched my partner at the time have her entire "groove" thrown off when I would forget to put the stylette in place.

The last code I had last month, as I went to intubate I realized I had forgot the damn stylette again, but was still able to effectively and on the first attempt pass the tube.

I would consider it adapting to your surroundings. Things happen.

Part of the problem we have in EMS. It is called Cowboy medicine.. we need to leave the ego's at the door.

I see that all the time. However, I have been informed that my "ego" is not "big enough" to be a good paramedic. I don't consider it a personal failure if I cannot get an IV, and will not use my patients as pin cushions in the attempt. I practice the 2 attempts to intubate before going to the King Airway, and on one patient went straght to the king as I could clearly see I wasn't going to get that tube. I think my point is.... I know I have limitations. I know I have a ton more to learn. And apparently, I need to go find a larger Ego if I am going to "compete" with the Medics around me.......

 

[Ridryder911]

I had to learn to intubate without a stylet for Flight and specialty transport including NICU.

In L&D you are expected to be able to intubate the meconium babies quickly with at least two passes and a stylet can get in the way. You have to do this before that baby decides he/she wants to take that first big breath.

The point the doctor was probably trying to stress, especially in emergent situations, is that a stylet is not always necessary. I have seen too many paramedics and others (RTs, MDs, PAs, NPs) actually lose focus and go to pieces because some piece of equipment like a stylet is not available. I'm sure this Anesthesiologist has seen this happen many times while training all the different professionals. By introducing a new intubator to this actually can make them stronger in the long run.

If it is available, use it. If for some reason you don't have it, you should know that you can still accomplish the task if necessary.

I understand that perceptive as well. I have seen too many that was taught or their success is dependent upon if they have a "Mac or a Miller".. Fortunately, I was taught that both is an excellent device.. hint: Alike said, never be dependent upon a piece of an equipment.

The point I wanted to elaborate is that too many newer medics, now brag about "tubing" or some other procedure "without this and that".. and only to demonstrate otherwise. Apparently we have a problem, look at the results. I don't believe removing a "gold standard" skill because we have failed to educate properly. I also believe it would be wise to introduce and teach to use all available equipment, until they have totally mastered the skill. Even if one intubation is missed, that is too many. I carry a trigger tube, in my personal bag for work. I work in a predominantly area where the ethnicity make up have a "no-neck" syndrome, very anterior aspect. I have found it is much be better prepared than to have deal with the feces to the fan syndrome.

Anesthesia unfortunately, have became are enemy instead of our allies in EMS education. As one that fully understands the risks of poor training and education, it would appear that they would only want and produce only the best. I had an EMS Instructor state meeting yesterday, and one of the topics was the difficulty on obtaining clinical sites. O.R. is one of the hardest and now almost all schools are having to pay for intubation clinicals. This is now making itself in other areas as well. I would hope that anesthesia professionals would at least be sympathetic and enforce to see that airway management is taught thoroughly and correctly.


R/r 911

 

[emtlady76877]

I am also supposed to be able to look at a person and tell if he/she will be hard to intubate if they needed to be.

 

[Ridryder911]

I am also supposed to be able to look at a person and tell if he/she will be hard to intubate if they needed to be.

Very true, few are taught Mallampati score, also Mallampati classification, Cormack-Lehane classes, as well LEMON. Each person that intubates should be very familiar summing up potential difficulties before they proceed.

R/r 911

 

[VentMedic]

I am also supposed to be able to look at a person and tell if he/she will be hard to intubate if they needed to be.

As an RRT, I assess by the LEMON method ( (Look–Evaluate–Mallampati–Obstruction–Neck Mobility). As RRTs we are QA'd constantly but have the advantage most of the time to pick the right equipment before an attempt is counted as a failure. Our MD residents are also taught this so as the RRT we may be bagging for up to 20 minutes as the attending goes through all of his lecture and demo point.

http://www.rtmagazine.com/issues/articles/2007-03_03.asp

Receding chin, neck extension, mouth opening, teeth, tongue size and thyromental distance are some of the things to consider for intubation success predictibility.

There is actually a whole scoring system that can be utilized and some anesthesiologists utilize it.

Darn Rid! You quick!

 

[MSDeltaFlt]

Rid, you're right, partly, about needing a cold room in order to intubate without a stylette. Although you do require a cold room in order to get the ETT tip bent into the other end then to stay fixed in that position, what it also takes is PROPER POSITION. Not just the pt with a pillow underneath their head plus the level of the bed must be at the proper height, but also YOUR proper position. You also need to use your center of gravity and the like.

When you do these things, you're able to intubate while not using a stylette. It's just not very practical in the back of an ambulance... especially one doing 90.

 

[Ridryder911]

Your right about positioning. Some years ago (late 80's-90's) it was popular trick to intubate while laying beside your patient. It was very successful as it taught the value to get in position of your patient. So many do not understand the "planes" and right angles. Something we maybe not emphasizing enough. As you noted in positioning the patient. Another trick other than padding under the shoulders, is to place the pt. on a LSB and pull the patient up & slightly allowing the head to drop off (of course non-traumatic).

Again, so many "rush" to get the tube.. when as long as your ventilating the patient well with supplemental oxygen, you can take the time to prepare your equipment and assess the patient, then verify (which is very essential both assessing with lung & epigastric sounds, and per mechanical EtCo2 detector. I highly suggest one with a wave form and print out (LP12 or similar) for documentation purposes & another tool for assessing.

R/r 911

 

[bonedog]

I also agree with Rid on the stylette. Having been one of those that was proud to never use a stylette, until the hot muggy day, watching the tube "wilt" as I tried to enter the anterior airway. Now I always put one in as I hate having to go in twice.

I would never deny anyone any tool they require. Situations on the street an anethestist wouldn't encounter. Same with having the advantage of a premedicated, pre-oxygenated patient, as opposed to the hypoxic, acidotic, combative patient we are often accustomed to. ( next to never in a position of comfort either)

The AIME course is excellent, covers all the adjuncts and LEMON.

 

[MSDeltaFlt]

Your right about positioning. Some years ago (late 80's-90's) it was popular trick to intubate while laying beside your patient. It was very successful as it taught the value to get in position of your patient. So many do not understand the "planes" and right angles. Something we maybe not emphasizing enough. As you noted in positioning the patient. Another trick other than padding under the shoulders, is to place the pt. on a LSB and pull the patient up & slightly allowing the head to drop off (of course non-traumatic).

Again, so many "rush" to get the tube.. when as long as your ventilating the patient well with supplemental oxygen, you can take the time to prepare your equipment and assess the patient, then verify (which is very essential both assessing with lung & epigastric sounds, and per mechanical EtCo2 detector. I highly suggest one with a wave form and print out (LP12 or similar) for documentation purposes & another tool for assessing.

R/r 911

Careful about the LSB and allowing the head to drop a bit. If you over do it, it will act like hyperextending the neck making the trach more anterior. As you said, it is easy to rush into a situation and make a difficult airway more difficult and end up shooting yourself in the foot.

You know you've had a difficult airway, either successful or not, when an anesthesiologist says he/she wouldn't have wanted to attempt tubing them.

 

[bonedog]

A video clip in the AIME course shows placing a mobidly obese patient in a semi-fowler's position to align the planes and facilitate intubation.