Quick Trache II and KingVISION

[Fish]

The reason(s) why "most medics" who get said average 10 ETT's per year? Simple. They don't retrain. Regardless of clinical field regardless of level of expertise, the teachers, leaders, innovators, trail blazers will teach technique over and over and over again until those learning are blue in the face... and then they keep going over it some more.

And the phrase "getting a tube" when referencing airways (please believe me when I say I do not want you to feel I'm singling you out), is one reason why these new gadgets (I call "crutches") are needed. Now Grade 4 airways are extremely difficult and even the masters (MDA's and Laryngoscopists) won't get them all. Because there is a big difference between "getting a tube" and "getting an airway".

The key to all of this is:
Slow down/"ooh-sah" (read: don't rush)
Maintain your situational awareness
Use proper technique

In that order.

Remember, Grade 3's & 4's are not that common. The majority of the problems I've seen with intubations (witnessed, first hand [yes I'll admit], chart review, and case study) have all been because of a lack of the aforementioned above. The patient being the cause would be an even more rare occasion.

And because focus has been turning more towards those rare instances that fall beyond technique, technique in and of itself is being disregarded more and more. And I honestly believe it is a great disservice to ALL medics by doing this.

I agree with all of this, In my career I have probably attempted intubation somewhere around 40 times the "old school" way, always had best success when I implimented "The key to all of this is:
Slow down/"ooh-sah" (read: don't rush)
Maintain your situational awareness
Use proper technique"

That being said, my success rate was probably 80-85% if I had to guess doing it the old way. My success rate with King Vision is 100% after 5 attempts.

To me it is a no brainer to go with the device that almost assures a 100% success rate the first time when used correctly.

Generally speaking, Medics do not have access to cadaver labs, OR, or ERs for intubations once they are hired and in the field. All we get are mannequins to train on and the occassional RSI and CPR call to intubate. It takes a very long time to gain experience and become good at it. These devices are going to be the new normal, just like 46young suggested.

I understand where you are coming from with technique and such, but when you get down to the numbers of it. A 60-65% first pass success rate old school, or a 95-100% success rate new school, new school or "new norm" is the way to go.

I work in a mix of a urban/suburban/rural EMS service. On average I get 7-12 intubations a year, we are dual Medic so double that for amount of calls I go on that have a patient needing intubation. It is my understanding that this is a "Medium" amount of intubations, some providers in some systems see more, some see less.

 

[46Young]

I agree with all of this, In my career I have probably attempted intubation somewhere around 40 times the "old school" way, always had best success when I implimented "The key to all of this is:
Slow down/"ooh-sah" (read: don't rush)
Maintain your situational awareness
Use proper technique"

That being said, my success rate was probably 80-85% if I had to guess doing it the old way. My success rate with King Vision is 100% after 5 attempts.

To me it is a no brainer to go with the device that almost assures a 100% success rate the first time when used correctly.

Generally speaking, Medics do not have access to cadaver labs, OR, or ERs for intubations once they are hired and in the field. All we get are mannequins to train on and the occassional RSI and CPR call to intubate. It takes a very long time to gain experience and become good at it. These devices are going to be the new normal, just like 46young suggested.

I understand where you are coming from with technique and such, but when you get down to the numbers of it. A 60-65% first pass success rate old school, or a 95-100% success rate new school, new school or "new norm" is the way to go.

I work in a mix of a urban/suburban/rural EMS service. On average I get 7-12 intubations a year, we are dual Medic so double that for amount of calls I go on that have a patient needing intubation. It is my understanding that this is a "Medium" amount of intubations, some providers in some systems see more, some see less.

I'm with you. We don't routinely start fires with sticks any more, do we? These intubation aids should become commonplace at some point. If services cannot afford this equipment, then they'll just do the equivalent of rubbing sticks by intubating the old-school way. Nothing wrong with old school, but IMO it's closed-minded to disallow tools that make our jobs easier. Even just having a bougie has helped me out a few times. "Click click click" you know what I'm sayin? Much better than having to sit up a mallampati IV obese pt against a wall and "ice pick" them to get a tube just so we could pronounce them per protocol instead of boarding them and carrying 300 - 350 lbs of significant injury potential down 3-4 flights of stairs.

 

[jwk]

The problem with routinely using devices like a GlideScope, KingVision, etc., is that you become dependent on them. There ARE patients that we still have trouble with using a GlideScope, most commonly with the fact that the blade is rather large and with a patient with a small mouth, there isn't enough room to get the tube in and maneuver it. Sometimes the old-fashioned way is the best way, but it's the classic "if you don't use it you lose it". I already work with anesthesia providers who have become dependent on using a GlideScope as a crutch for every potential difficult intubation. At least for anesthesia, I think that's a bad thing, but for EMS, perhaps not since your situations are far less routine than mine are. But you have to remember - technology doesn't always work - bad batteries, bad camera, broken blade - all those things will happen, and at the worst possible time.

 

[Mad Russian]

My service utilizes both the Glidescope and the Kingvision meaning one truck has the glidescope and the other two carry the King, I like both but prefer the King to the Glidescope.

 

[Handsome Robb]

My service utilizes both the Glidescope and the Kingvision meaning one truck has the glidescope and the other two carry the King, I like both but prefer the King to the Glidescope.

Any particular reason as to why you prefer it?

 

[Mad Russian]

Basically not a fan of the ridgid stylet used with it generally if I utilize the glidescope I use an ET Introducer rather than the stylet provided.

 

[medicsb]

I'm a little "eh" on the idea of video laryngoscopy, even in the ED, as being the primary means to intubate. There does seem to be a lot of research into it for EM and anesthesia and in experienced hands they both have similar overall success rates. A recent study showed VL to have higher 1st attempt success, but DL to be better if subsequent attempts are required. VL also had fewer accidental esophageal tubes. (J Emerg Med. 2012 Apr;42(4):400-5.) So, it certainly has a place.

I think it is better to use it as a back up device if you're intubating frequently, and better to use as primary if less experienced, thus I think this is preferable for most medics. Personally, I'd prefer to use a video stylet or a fiber-optic stylet (e.g. http://www.airwaycam.com/Malleable-Optical-Stylets.html).

 

[Christopher]

Basically not a fan of the ridgid stylet used with it generally if I utilize the glidescope I use an ET Introducer rather than the stylet provided.

The stylet is designed to accommodate the extreme angle of the axis when moving the tube around the blade. A rotating motion where your hand mimes a downward facing "C" works best, stopping just shy of the glottic opening when you pop the stylet out 1-2 cm with your thumb to loosen up the tip of the tube.

I'm also interested if you're using Parker/ski-tipped tubes with the glidescope as that makes a noticeable difference.

 

[Christopher]

I'm a little "eh" on the idea of video laryngoscopy, even in the ED, as being the primary means to intubate. There does seem to be a lot of research into it for EM and anesthesia and in experienced hands they both have similar overall success rates. A recent study showed VL to have higher 1st attempt success, but DL to be better if subsequent attempts are required. VL also had fewer accidental esophageal tubes. (J Emerg Med. 2012 Apr;42(4):400-5.) So, it certainly has a place.

My current complaint with most VL devices is they require different mechanics than DL. Paramedics were not taught how to use DL correctly to start with, and now we're asked to appropriate use devices which are not just pushing a tube forward towards the glottis. Worse, most of the learned-skills to troubleshoot DL going wrong don't apply with any higher-angle VL device.

The ideal device prehospital will be Mac-like and use roughly the same mechanics as DL. If you can't get it with that, it is one of the true difficult airways (~5%) and an SGA will be adequate.

I think it is better to use it as a back up device if you're intubating frequently, and better to use as primary if less experienced, thus I think this is preferable for most medics. Personally, I'd prefer to use a video stylet or a fiber-optic stylet (e.g. http://www.airwaycam.com/Malleable-Optical-Stylets.html).

Fiber-optics are pretty slick and I really enjoyed using them, I think the combination of an LMA and a fiber-optic scope would be great for EMS. Especially if you've got an elbow-connector that would allow you to ventilate while you feed the scope. Ambu makes a disposable one that is relatively simple with decent enough optics.

Or you can go iLMA and a Levitan...lots of options!