VL exclusively

NomadicMedic

NomadicMedic

I know a guy who knows a guy.
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Does your service mandate video laryngoscopy? If so, how did you make the change? What drove the change? How did the medics react? Did your first pass success rate improve? What VL are you using?

Can you tell I want to know everything?
 
We have king vision, and it's at the discretion of the medic to use it, or just stick with DL. Personally in intense situations I will use DL and a bougie. I could care less about the "status". I need to take an airway and I get it first time. First time pass attempts are much higher with VL where I'm at. But some of the old school medics cry about it and laugh when you use it. I've done plenty of DL especially through my OR clinical locations. I'm not to worried about impressing anyone.
 
It isn't mandated, simply provider choice. We carry McGrath's on the supervisor trucks and they respond to all cardiac/respiratory arrests and other such calls. The McGrath is frequently used though, the last few intubations I've had supervisors do have all been done with a McGrath. Purely anecdotal, but it seems like our supervisors tend to go for the McGrath first and field medics DL first. That may also be due to the fact that those intubations were all on scene without the luxury of perfect space and positioning.

I don't use the McGrath as my first line. I typically go Mac/Miller 3--->McGrath--->King. My reason is simply to keep some familiarity with DL in the event that VL isn't an option. That being said, I keep the time I will look fairly short before resorting to the next steps in my plan and usually do have an easier time getting a good view with VL.

What is mandated is that we use a bougie on all intubations. I prefer preloading mine and use the method the CRNA Bonjo Batoon made a video showing. It's proven to be a stable way to preload and easy to manipulate.

I don't know what the success rates are between DL vs VL. I tend to have an easier time using VL and I imagine that is pretty universal, but I can't speak to the exact numbers. I would say what has helped me the most isn't the laryngoscope (not that it hasn't been beneficial as well), but positioning and padding. The majority of our intubations are done during cardiac arrests and the autopulse will rock that head all over the place. Stuffing a bunch of blankets gives a stable platform and view. That and ramping the head up a little bit to change my angle have proven to be the biggest help since I've worked here.

I think one thing that doesn't get enough attention is the prep work BEFORE an intubation that makes it successful. I wouldn't be opposed to VL being mandated, but I do think that more emphasis needs to be placed on what we do before we even touch the laryngoscope.
 
VL hasn't made its way to our corner of the world. A buddy of mine who is doing his internship in a neighboring divisions told me that the FD is going through a "trial" period with VL. Don't know the brand, but my buddy said that got the tube on a full arrest. Based on how he described it and what he's seen with his interactions with it, it sounds just as good if not better than DL. Me personally if given the option of VL or DL I would be going for the Mac 3 or 4 first, just to keep those skills relatively fresh. Yeah VL is extremely helpful and all, but technology fails and as everyone knows in the moment where you need a tube it ain't going to be working.

As StCEMT has said, prep work is everything. I find taking the extra couple of seconds to ensure the pt is properly positioned and padded makes life easier. It will be interesting to see if we get VL in the future. I personally would like to see it.
 
VL and bougie mandatory with our VL being mcgrath. Im fine with it being mandatory as i use the mcgrath DL anyways and just use the video for a reference if i need to. Our FPS is about 95%+ which is good i think considering we get all the hard airways because if they were perceived to be easy the ground would have done them PTA.

The king vision is popular down here and my opinion of it is not good. Ive come up on so many airways where the medic is pounding away at it.

As the ones above me had said the prep work is what really makes a difference. I still undo the c-collar, ramp, ear to sternal notch and suction every patient.

Rebel EM just reviewed a study about bougie FPS with cmac.
 
Just like ultrasound for line and nerve block placements took a while but is now unquestionably considered the standard of care, I'm pretty confident there will be a time not too long from now when VL is considered the standard of care.

There's quite a bit of research on VL vs. DL in the ED setting, with all of the studies showing anywhere from no advantage to a significant advantage (and most showing at least some advantage) with VL, and none that I know of that show VL as inferior to DL. The advantages of using VL will increase as the devices become better and more affordable, which is already happening compared to the first generations of them.
 
Quite simply, we don't have them on every truck when I was still working EMS. IIRC, out of 9 trucks in the system, we purchased two, and they were given to the two supervisors (who responded on all cardiac arrests, but never beat the ambulance to the scene). So their real world use was pretty limited.

They look awesome, they are expensive, and they are new to EMS. And it should increase success rates.

But like many things in EMS, the old school will push back "we didn't need those fancy things to intubate back in the day," the new school will like them but not want to be seen as requiring a crutch to do the job (at least that is what they will hear from their FTOs), and if they aren't maintained by administration, and technologically updated as needed, the field personnel's view of them will not be positive.
 
DrParasite said:
Quite simply, we don't have them on every truck when I was still working EMS. IIRC, out of 9 trucks in the system, we purchased two, and they were given to the two supervisors (who responded on all cardiac arrests, but never beat the ambulance to the scene). So their real world use was pretty limited.

They look awesome, they are expensive, and they are new to EMS. And it should increase success rates.

But like many things in EMS, the old school will push back "we didn't need those fancy things to intubate back in the day," the new school will like them but not want to be seen as requiring a crutch to do the job (at least that is what they will hear from their FTOs), and if they aren't maintained by administration, and technologically updated as needed, the field personnel's view of them will not be positive.
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FWIW, we have a KingVision on every truck. The use was mandatory and has fallen by the wayside through attrition.
I'm working on rebuilding the clinical competency here...
 
NomadicMedic said:
FWIW, we have a KingVision on every truck. The use was mandatory and has fallen by the wayside through attrition.
I'm working on rebuilding the clinical competency here...
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Might be a little off topic, but you are describing two different issues: 1) the KingVision is mandatory, and (for whatever reason) staff aren't using them and 2) clinical competency (which I am assuming means people aren't intubating successfully on the first attempt).

1) if the rules say you must do this, and they aren't do this, than progressive discipline should occur. They know the rules, they decided to ignore the rules, there are consequences. if you want to make the VL optional, paramedic discretion, another tool in the box etc, (which is why I encourage) do so. But if its mandatory, they SHALL use it every time, and they aren't, than you need to do something to correct that behavior.

2) if your clinical competency has decreased, and one factor you have noticed is many of the failed attempts did not use the VL, have an QA meeting with the involved paramedics. The reason: failed to secure airway. secondary reason: failed to utilize all the available tools provided by the agency in order to attain the goals. If they can do it with DL, awesome, you are trusting your paramedics judgement in what they feel comfortable using (we have the same arguments for ETT vs Kingtube on cardiac arrests). But if they are unable to do the DL, and for some reason are still resistant to using the VL, than that requires either re-education or counseling on what is best for the patients.
 
KingVision is mandatory at AMR here. We still carry DL equipment but it is not to be used as a first attempt unless there is some untoward situation which has yet to apparently occur. The old DL success rate was 60%, with the advent of the KingVision success rates stayed the same and then actually dropped. Turns out you have to train people when new equipment is implemented, once that happened the success rate climbed to around 90%. I am not sure what the first pass success rate is.

My fulltime job has McGraths on every ambulance. It's provider choice on whether you want to use it or not. Every medic but one does, he is of course my captain.
 
We have a choice but VL is strongly encouraged for most situations. We use the C-Mac and many providers will do traditional DL at first and only look up at the monitor if needed. I think its a huge benefit to have a traditional blade as opposed to proprietary or hyperangulated blade like some VL so you can transition VL -> DL if needed. Our company wide first pass success rate is very good (~93%, n~1,000) even with many novice intubators (RNs).
 
Only my division (CCT) has VL capabilities. I wish it was mandated across the board for all ground crews, and perhaps even CCT crews. If my patient even looks so much to be a troublesome airway, protocol or not, I’m going straight to VL—>King Airway.

My personal opinion is that—given our infrequency with ETI—it should do away with DL in the prehospital setting altogether. As it is we struggle with what’s given now, and all most (piss poor) paramedics do is piss and moan about losing this “crucial life-saving skill” (insert gag).

I do agree with doing away with hyper-angulated VL blades/ models, but as of now, the first generation models are somewhat in their “trial phase”. Dr. Kovacs has a pretty good tutorial on the two different models.

Again, given the haphazard job that we (collectively) do in the field we don’t necessarily need DL if VL is constantly proving its superiority; then again, I’m content with an RSA being standard in the out-of-hospital setting.
 
Kingvision VL is the de facto default at Creek, with both styles of blade and the CoPilot rigid stylette, or bougie. I like the idea, but I don't think that the Kingvision is a particularly fantastic bit of gear. It works, but I would prefer a McGrath or CMAC.

I really, really would like to carry Igels and McGraths.
 
RocketMedic said:
Kingvision VL is the de facto default at Creek, with both styles of blade and the CoPilot rigid stylette, or bougie. I like the idea, but I don't think that the Kingvision is a particularly fantastic bit of gear. It works, but I would prefer a McGrath or CMAC.

I really, really would like to carry Igels and McGraths.
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CMAC and igel is pretty much all anyone ever needs. Really great pieces of equipment.
 
Remi said:
CMAC and igel is pretty much all anyone ever needs. Really great pieces of equipment.
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While my experience is purely with a McGrath, if I had to choose any two airway devices it would be these. I miss the igel, that was my favorite of all the SGA's.
 
So I’ll start with this.

http://www.wilco.org/Portals/0/Departments/EMS/King Vision Intubation.pdf

We made the change based on data. Our Medical Director looked at our FPS rate with DL and wasn’t happy and so we switched to VL and conducted that study.

We now exclusively intubate using King Vision (with a #3 channeled blade) since the conclusion of this study. The only DL we do is intubation/airway suctioning for meconium aspiration and removal of FBAOs when the King Vision won’t fit. We went from a 40-50% FPS with DL to a routinely having over a 90% FPS rate with VL.

That high FPS rate is a combination of detailed training in our New Hire Academy where you learn how to use the King Vision “the Wilco Way,” learning SALAD with dummy training, monthly training/skill sign offs with a Senior Medical Officer and a robust QA process for each intubation attempt.

My personal views here, King Vision is a great product, but I wish it had more features like video recording as it would aid in training and QA.
 
Good stuff. The reason I asked was because I want to move our service to the WilCo method of intubation. I may reach out to Dr Jarvis and see if I can take a WilCo airway class and bring the method back home.
 
NomadicMedic said:
Good stuff. The reason I asked was because I want to move our service to the WilCo method of intubation. I may reach out to Dr Jarvis and see if I can take a WilCo airway class and bring the method back home.
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There is a youtube video entitled intubating the Williamson county way or something like that. Its pretty good, you should watch it. Im a big believer in standardizing airway protocols and procedures. When i was a wee little medic i remember the all the veterans had their own way of doing everything "well i like to do it like this blah blah blah" in reality there shouldn't be any specific way. There should be what works IE: bougie everytime, 2-hand seal everytime, peep valve everytime, head in ear-sternal notch everytime etc. and while i mayyyyy disagree with some of the things Dr. Jarvis says/does i do respect him for going in a standardizing such an important aspect of our profession. And then proving that it works.
 
NomadicMedic said:
Good stuff. The reason I asked was because I want to move our service to the WilCo method of intubation. I may reach out to Dr Jarvis and see if I can take a WilCo airway class and bring the method back home.
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Are all your trucks (or will they be) outfitted with video laryngoscopes or is that only on supervisor trucks?
 
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