Intubation woes

[zmedic]

My advice is to say out loud what you are doing and seeing. This is helpful for a few reasons

1: It calms you down

2: It reminds you what you are doing (by saying what you are supposed to be doing at that point in the intubation it reminds you to do it.

3: You get more time to try the intubation if the person supervising hears that you know what you are doing, and if things are going well, they know what you are doing to correct the situation and are not just staring and the esophagus. Example:

"I'm opening the mouth wide, inserting the blade to the right and sweeping the tongue. I'm clearing the lips, I'm lifting to the opposite corner of the room. I see the epiglottis, I'm advancing into the valecula and pulling up. I see the cords, tube please. I have a grade 1 view (if you do), I see the tube passing through the cords. (hook up bag) I see chest rise, I have tube fogging, I have good C02 capnography. Equal breath sounds over the lungs and nothing over the belly."

Sounds dumb but that's what I was doing in anesthesia and I wasn't having people bump me out of the way after 5 seconds like some were.

[Doczilla]

When I was a third year medical student on surgery rotation, we had a patient in his late 30s-early 40s with a large pleural effusion (fluid around the lung). He was doing okay on a NRB mask as long as he remained seated upright, but each time we laid him down, he would desaturate. He needed a chest tube to drain the fluid so he could breathe. As a med stud, I was eager to do the procedure. We were on a med-surg floor. I brought the appropriate gear, gowned up, and prepped appropriately. I thought through every step of the procedure: when to put on the sterile gloves, how to position him, filling the bowl with betadine before putting my gloves on, drawing up the right amount of anesthetic and what size needle to use, getting the right scalpel, setting up the Pleurevac and filling the chamber with water, suture, foam tape, everything. The attending, a surgeon who has been cracking chests since the year I was born, stepped into the room, looked around, then out into the hall, looked around, then back into the room. "Transfer him to ICU. We'll do this later." Disappointed, I put the kit away to be resterilized, knowing that it would be done by someone else.

Later, we had our daily wrap up meeting between the attending and 4 of us med students. He asked, "Do you know why we decided not to do the chest tube then?" Not really. "How many nurses were in the room helping you set up?" None. "How many nurses did you see in the hallway or at the nurses station ready to jump in if things went sour?" None. They were all in patient rooms, going about their duties, taking care of the patients on the floor. "Do you know if they are experienced running codes? Do they know where all the code equipment is on this floor? How much practice do they get? We know that the resources are available in the ICU, that the nurses there run codes all the time, and know where the equipment is. If something happens, you know there is manpower there to jump in." He meant this neither as a slight to the MS floor, nor a ringing endorsement of the ICU, but a reflection of the bigger picture of anticipating where we would be.

He continued. "I'm not thinking about the procedure. I know I can put a chest tube in. I can do it with my eyes closed. I'm not worried about that. What I'm thinking about is, what happens if the patient decompensates? You always have to be thinking ahead of the procedure. Your mind has to be one or two steps ahead, preparing for that event that comes next. Otherwise, he goes down the tubes and you aren't ready to deal with it."

I preach this to my residents. Don't get lost in the procedure. Intubation is a physical skill of muscle memory, not a mental exercise. Your practice has taught your hands how to intubate. You know how to intubate, and if you are thinking only of this, you will miss the big picture. When you are in the ER, the OR, the ambulance, or on the street, take it all in. Think beyond the immediate, and wrap your mind around what comes next. Don't think, "I'm going to intubate." Think, "this is what I will do if I can't intubate. These are the parameters that will tell me if I need to intubate, or just give oxygen. This pulse ox level is when I will quit attempting to intubate and bag the patient. This ETA will determine if I need to tube now, or use other methods to support the patient until I get to the hospital." Concentrate on where you are going, rather than how you get there. The little things, like the procedures, will flow.

'zilla

[Kiwiology]

Use a bougie; its damn near impossible to fail with a bougie and it means you dont have to piss around using a stylet, I don't like them.

[chbare]

Spoken like a true professional, thanks Zilla!

[Kiwiology]

Spoken like a true professional, thanks Zilla!

What a magnificent post I agree

As I learnt doing adrenaline upskilling the decision to do something is more important than the physical action of doing it.

[systemet]

Great post from 'zilla.

I'm reluctant to even try and add anything to it. But I just wanted to say that when I do an intubation on someone with a pulse, I'm pretty anal about how I set up.

* I check the suction works first, I jam the Yankauer in it's cover under the pillow

* I have my tube lubed, styleted, tested; I have a tube size smaller placed on the bench.

* The Bougie is out on the bench

* I've taken out the backup device, checked the cuffs

* The cric' kit is on the bench, or beside me

* Drugs are drawn up

* The patient's all wired for sound, (e.g. ECG, SpO2, NIBP) and the capnograph is on the bagger

Then I take a second to let everyone know where everything is. Then I tell them the plan, e.g. "I'm going to try and intubate with a styletted 9.0, and I want you to put your hand on the thyroid and hold it there. If that fails we're going to back out, and either try with the Bougie, or place a combitube".

I've had a few people react negatively to this, especially to the cric' kit. More than once I've heard "We're not going to need that!". But the reality is, you can't always predict when you're going to run into problems. If you're going to push the drugs, miss the tube, and get into a can't intubate can't ventilate situation, it's going to be easier if the kits already out and everyone knows where it is. [it's also a great way to know that everything's there, before you start.]

This may not be exactly revolutionary -- I'm sure most of us do this. But I just wanted to throw it out there.

[Kiwiology]

I like the way you think, but why not try the bougie first; if you get it in there's an absolute 100% guarantee you've intubated the trachea when you slide the tube overtop.

Maybe it is just me, but I do not like using styleted tubes, I have used them a small number of times and just didn't really think it was for me

[systemet]

I like the way you think, but why not try the bougie first; if you get it in there's an absolute 100% guarantee you've intubated the trachea when you slide the tube overtop.

Maybe it is just me, but I do not like using styleted tubes, I have used them a small number of times and just didn't really think it was for me

I don't think it's necessarily wrong to use the bougie first. I might do this if I was intubating someone in C-spine, or a predicted difficult airway. But I used to use a styletted ETT on my first attempt to keep the skill of passing something a little wider through the cords. I didn't want to get into the habit of relying on something that one day might not be there. (Granted, it should always be there if I have a chance to check the truck, but sometimes you come on shift and walk straight into a call, or use the last one on a code, and don't get to get to restock it before hitting another call, etc.)

* As usual, remember that I've not be working in the field the last little bit, so I don't claim to be current on everything.

[Kiwiology]

Good point,.I can use a styletd tube if I absolutely have to its just.my strong preference to use bougie

[BillKaneEMT]

Good point,.I can use a styletd tube if I absolutely have to its just.my strong preference to use bougie

What about this one?