Intubation woes

[Kiwiology]

I would still perfer an elastic gum bougie

[Vorenus]

What about this one?

This looks funny.

Never heard of it before.

[DwayneEMTP]

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

+5. That gets my vote for post of the year so far...

What a perfect picture it draws of the dangers when a providers ambition is combined with mental/experiential frailty...Not that most of us would know anything about that...

Of course the opposite is just as often, or perhaps even more so true in my experience. Providers paralyzed from the 'what if I can't' toxins coursing through their veins. Not just in intubations, but in pushing any new med, starting IVs, using CPAP....What a challenge it can be to plan the multifront assault of attacking with confidence while defending your flanks against ill preparation.

Excellent thread!

Dwayne

[Paramagic]

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 work with a fair number of medics who take the same approach. I disagree with it. The bougie is the first step in the difficult/failed airway approach for most of us. If things go wrong it is important to change something in my technique and If I have already used the bougie I now have one less thing I can change, one less step in the failed airway route, one less chance of successfully intubating.

If I am predicting a shitty airway for whatever reason, then I may break out the bougie straight away, but otherwise I want to give myself every opportunity to pass the tube successfully.

I also do as zmedic does, verbalising everything, even when I am the senior medic at the scene. Intubation is a two medic job here, so I like to let the other medic know what is going on. I also like them to do the same for me, so that I know if things are going south, rather than sitting in silence, sweating, wondering if they are going to get the job done, whether I should step in, whether we should abort the attempt and so on.

Doczilla also raises very important points. We have a 99% success rate for intubation, and a decent part of that is not just knowing how to intubate, but when we should intubate, or when we should leave it to someone else.

[runswithneedles]

I understsand where all of you are coming from. That is why im reading up on it further. My next OR clinical comes in a month. Hopefully Ill better luck. And maybe more sleep.

This looks funny.

Never heard of it before.

looks like a boogie.

[chbare]

No, it's a type of hybrid lighted stylette. The Bougie can be used like a stylette, but can also have additional uses such as tube exchanger, difficult intubation adjunct and even as a method of proper tube placement verification.