Etomindate

[VentMedic]

It has always been my understanding that the Glidescope is a RESCUE tool, where DL should be used primarily. If you can't get it with DL, move to a different tool. Of course, not all the residents at the hospital I work at follow this thought process. Hope they don't go to a hospital that doesn't have any of the fancy stuff... :?

It is also the sign of being a progressive provider or healthcare system that gets equipment to make any "skill" a little easier and maybe safer for the patient.

If others in EMS want to hold on to just one way of doing things, no wonder some EMS providers still do not have access to the 12-Lead EKG or ETCO2.

It will also be these doctors that will have a higher level of expectations for knowledge and technology. Thus, they may bring whatever system they decide to work in up to the 21st century.

That was my understanding as well. I first saw it in use about a year or more ago. the glidescope reps were in the ER and they (the docs) were finding every excuse under the sun to intubate people. theyd bring this thing bedside like it was the holy grail or the original napkin used at the last supper. the crowd would Ooohhh and AAAhhhh. The doc using it had used it in some airway course and got the tube first time. They also pulled out the lighted bougies, it was like an intubation expo.:

Considering the cost of the GlideScope, it is an ooohh and an aaaahhh for a hospital to purchase one.

What do you have against technology? These doctors may go on to services that require an extensive knowledge of many intubation devices. Not everyone is happy to be skilled at only one way of intubating.

Ive also seen people use the bougie (never used it myself) and directly insert it while visualizing the cords. Im like, well if you can see the friggin cords, why not just pass a tube instead of this stupid thing? I thought the bougi was to be used blind... :?

It does sound like you have do very limited airway experience or knowledge about alternative devices to assist in difficult intubations. Thank goodness the doctors at your hospital are willing to try new things and seek devices to make difficult airways more manageable if the Paramedics or at least you aren't.

[chbare]

As stated, the glide scope is a great tool and very effective. However, the technique for using the glide scope is quite different from traditional laryngoscopy. Somebody using the glide scope should have a good understand of how to properly use the device and have spent time working with the device under the guidance of an experienced operator. Intubating in theatre under the watchful eye of an anesthesia provider who is well versed is using the glide scope for example. I would hate for somebody to blow off a device or technique because they saw another person use the said device/technique without success.

Actually, you can use the bougie in many different ways. I have seen people use it like a stylette/stylet. In addition, I have used it to exchange a couple of tubes where either the cuff was not functioning or the tube was too small for the patient. I have also seen people opt to use the bougie if their airway assessment indicated potential difficulty. Then, they ended up having a high POGO and simply inserted into the glottis, then placed an ETT. Obviously, people can also use the bougie with poorly visualized glottic anatomic structures. Then, note the presence of tracheal clicking and stoppage for confirmation.

You see, many options are available and people have the ability to use several techniques. Personally, I am a big fan of the bougie. I would not call it stupid, I simply like having additional options. The bottom line is having enough experience and understanding to properly use the said tools and techniques.

Take care,

chbare.

[CTXMEDIC]

nothing against technology there Vent. i just keep it in perspective. batteries and electronics fail. i never said it was a bad thing to have this equipment but theyre still just tools. granted more tools in the toolbox broadens your options for that difficult airway but even Craftsman have warranties

As for bougies, they definitley have their place. a tube exchange as the previous poster stated is a prime example. to always put a bougie down first seems like a waste of time if you can visualize the cords. theyre designed like they are so you can feel if its in the appropriate hole. if you can see that its in the trachea, whats the point? i guess you could hold the thing in place in case the cords start to spasm, then you give yourself a marker while threading the tube down.

[VentMedic]

nothing against technology there Vent. i just keep it in perspective. batteries and electronics fail. i never said it was a bad thing to have this equipment but theyre still just tools. granted more tools in the toolbox broadens your options for that difficult airway but even Craftsman have warranties

Did you know that there are over 300 different airways that these doctors may have to come in contact with even in a short career? The devices you mentioned are just a couple from a long list of "tools" that they will see for managing an airway. Just the number of different ETTs is staggering if one was to try and list all of them.

visualize the cords

Visualizing the cords may be just one part of the battle. You may be able to see very anterior cords but have difficulty positioning the tube directly due to other structures.

Hopefully you will see difficult airway management in a controlled setting so that you can learn some of these things before you get laughed at or your patient becomes part of the trach and peg club due to cord and throat trauma from repeated intubation attempts to save your "never miss" record.

[Arizonaffcep]

It is also the sign of being a progressive provider or healthcare system that gets equipment to make any "skill" a little easier and maybe safer for the patient.

If others in EMS want to hold on to just one way of doing things, no wonder some EMS providers still do not have access to the 12-Lead EKG or ETCO2.

It will also be these doctors that will have a higher level of expectations for knowledge and technology. Thus, they may bring whatever system they decide to work in up to the 21st century.

Very true...I just worry about those that use the rescue tool as front-line only...which there are a few who almost never use DL, they can loose proficiency in it, and once they graduate residency they can end up at a hospital that doesn't have anything else. Which would be detrimental to their patients.

[VentMedic]

Very true...I just worry about those that use the rescue tool as front-line only...which there are a few who almost never use DL, they can loose proficiency in it, and once they graduate residency they can end up at a hospital that doesn't have anything else. Which would be detrimental to their patients.

Physicians are usually responsible enough to adapt to the situations they are placed in by seeking guidance, education and training from their peers. If not, there may be a physician QA committee that will tell them if they are deficient and/or not grant them certain skills privileges until they prove proficiency. Their skills privileges will probably be listed clearly on the computer or procedure book in most hospitals.

Remember too that in the hospital, a little more is being done then just sticking a tube through the cords. We may record our intubations with the videoscope for teaching and/or diagnostic purposes. Some of the recordings may also show the damage done either by trauma from the initial incident or that which is caused by bad intubation technique.

The GlideScope is just one tool that offers a different approach. For some patients, such as those with burns, we will use the fiberoptic scope (also available as a convenient portable by Olympus) as an intubation tool either in the ED or burn unit. It may be assisted or not with DL. With some fiberoptic scopes we can achieve several tasks at one time while prepping for the tub and/or surgery as well as positioning specialty tubes since time may be a factor.

Have a Pulmonologist or ENT doctor show you his/her cabinet of devices used to view and access the airways.

If your sole purpose is to put the tube throught the cords, DL may suffice. However, it is good to also be knowledgeable about what alternatives are available and what advances are made available in medicine. You might also run into one of those 300 different airways that are not commonly seen by those in EMS on either an IFT or home care patient. Some "assume" a patient has just a standard ETT or trach and may not look closely at the device until something happens.

I guess it is no secret that I love my other career choice. It has been a great compliment to what I also do in EMS. At one time, I, too, was very cocky about my great DL intubation record. I got a serious attitude adjustment when I saw how much there was to learn about just establishing AND maintaining an airway. Still learning....

[Arizonaffcep]

Remember too that in the hospital, a little more is being done then just sticking a tube through the cords. We may record our intubations with the videoscope for teaching and/or diagnostic purposes. Some of the recordings may also show the damage done either by trauma from the initial incident or that which is caused by bad intubation technique.

The GlideScope is just one tool that offers a different approach. For some patients, such as those with burns, we will use the fiberoptic scope (also available as a convenient portable by Olympus) as an intubation tool either in the ED or burn unit. It may be assisted or not with DL. With some fiberoptic scopes we can achieve several tasks at one time while prepping for the tub and/or surgery as well as positioning specialty tubes since time may be a factor.

Have a Pulmonologist or ENT doctor show you his/her cabinet of devices used to view and access the airways.

If your sole purpose is to put the tube throught the cords, DL may suffice. However, it is good to also be knowledgeable about what alternatives are available and what advances are made available in medicine. You might also run into one of those 300 different airways that are not commonly seen by those in EMS on either an IFT or home care patient. Some "assume" a patient has just a standard ETT or trach and may not look closely at the device until something happens.

I guess it is no secret that I love my other career choice. It has been a great compliment to what I also do in EMS. At one time, I, too, was very cocky about my great DL intubation record. I got a serious attitude adjustment when I saw how much there was to learn about just establishing AND maintaining an airway. Still learning....

Please understand I'm not bragging on my intubation skills...I've been "rotting" in the ED for 2.5 years without a live intubation...so I'm sure I'm a little rusty...

The way that the airway tools have always been explained to me, and this is from one of the faculty I work with, an assistant professor of EM and is faculty for www.theairwaysite.com for Emergency, says the "standard" is DL. All others are nice to have, but you can't guarantee that they (being hospital, prehospital provider, etc.) will have them. So it is imperative that one be proficient in it. This Dr. also has more airway gadgets than anyone I know...

That's all I was getting at.

[VentMedic]

I

The way that the airway tools have always been explained to me, and this is from one of the faculty I work with, an assistant professor of EM and is faculty for www.theairwaysite.com for Emergency, says the "standard" is DL. All others are nice to have, but you can't guarantee that they (being hospital, prehospital provider, etc.) will have them. So it is imperative that one be proficient in it. This Dr. also has more airway gadgets than anyone I know...

That's all I was getting at.

I have nothing against DL and it can get the job done for most intubations. However a doctor or any provider should be open to alternative devices especially if their hospital has specialty units such as Burn or Head/neck surgery. If they are not open to learning different techniques and devices to better serve a unique group of patients, they may be doing their hospital a disservice. It can also save a doctor from calling in an anesthesiologist at 0200. Those that want to keep only one device in their tool box may be short sighted and one day may regret not broadening their skills, knowledge and available devices.

This can also apply to CCT and EMS crews that do IFT for hospitals with known specialities. The same statements can be said if the hospital in their area routinely does heart and lung transplants, microsurgery, ventricular assist devices and CHD surgeries.

Too many just accept or settle for the "standard" way of doing alot of things.

[Arizonaffcep]

I have nothing against DL and it can get the job done for most intubations. However a doctor or any provider should be open to alternative devices especially if their hospital has specialty units such as Burn or Head/neck surgery. If they are not open to learning different techniques and devices to better serve a unique group of patients, they may be doing their hospital a disservice. It can also save a doctor from calling in an anesthesiologist at 0200. Those that want to keep only one device in their tool box may be short sighted and one day may regret not broadening their skills, knowledge and available devices.

This can also apply to CCT and EMS crews that do IFT for hospitals with known specializations. The same can be said if the hospital in their area routinely does heart and lung transplants, microsurgery, ventricular assist devices and CHD surgeries.

You are absolutely right. Putting all your eggs in one basket is a recipe for disaster. The point I was trying to make was, one should not embrace the "gadgets" to the exclusion of DL, which I have seen with a couple of residents.

[VentMedic]

You are absolutely right. Putting all your eggs in one basket is a recipe for disaster. The point I was trying to make was, one should not embrace the "gadgets" to the exclusion of DL, which I have seen with a couple of residents.

These residents probably don't spend their entire 3 years in the ED. They may have been introduced to DL exclusively during another rotation. They now have the opportunity to use a device that they had not used during their other rotations. That is part of the purpose of rotating residents so that they will have different opportunities and different mentors. If at the end of their residency, they are only comfortable do something ONE way, then the teaching hospital and the residents have failed in their education.

Even for ventilators, Volume Assist Control has been the "standard" for regular ventilation for the past 15 years. Before that it was SIMV and before that IMV. However, in a good teaching hospital, they may have the opportunity to be exposed to HFOV, HFJV, NPPV, PSV, PCV, ASV, PAV, NAVA, APRV, PRVC, other variations of Bilevel ventilation depending on make and model of ventilator and and Independent Lung Ventilation. They may be introduced to various forms of ARDS and Ventilator Lung Injury prevention protocols. Proning, Nitric Oxide, Flolan, HeliOx, Nitrogen, CO2 and Partial liquid ventilation therapies may also be part of their education. They will also be taught at least two methods of A-line insertion. They will know what is appropriate and when. If they can only say VAC 500/12/+5 at the end of their many unit rotations, somebody has failed. Even if they end up in the boonies working at some local little general that is no excuse not to know the advances in medicine and to either make them happen at their facility or get that patient transferred to one that can. VAC can not be depended on to save a life even if it is a "standard" no more than DL will work every time and another alternative should be available along with a good comfort level for that equipment. Thus, residents are exposed to whatever at some length during each rotation.

However, at the hospitals I work at, the doctors will not have much and opportunity to perform a nasal intubation except to be made aware of it in a lab or if it is a Paramedic intubation from the field. Even in the OR for reconstructive surgeries a trach will be the alternative before nasal intubation if a tube is going to be in place for more than 48 hours. That is not to be said NTI still isn't done in some hospitals but we are going to give the residents enough education for sedation alternatives and intubation techniques so that they do not have to rely on it except in very rare cases. Field providers, of course, may not have that luxury.

BTW, my apologies for the intubation arrogance remark. That was intended to be directed at CTXMEDIC who got us to this point with his harsh critiquing of residents learning new modalities by laughing at them or casting insults. Besides just rude, it also gives these young doctors an impression of Paramedics that may not count favorably if they decide to specialize in EM.