Why can't I intubate?

[chaser]

.......intubated the other day and thinking of wine or beer St.Paddies and ol and this has been 17 yrs, Dr could not do it vocal cords punched...

huhh???????????? :-k

[Asysin2leads]

A lot of times I find people simply don't get close enough to the patient to get good visualization. I had this problem because of my height, and I've found on difficult airways I have had to literally turn my head sideways and get down to where the side of my temple is nearly resting on the patient's forehead. Remember, the structure you are trying to visualize is, depending on the size of the person, approximate 4 to 6 inches above whatever level they are laying. If they are supine on the ground, their trachea and epiglottis will be 4 to 6 inches above the ground, so if you are going to be able to get good visualization, you will need to get your eye level 4 to 6 inches above the ground. Also, people tend to not extend the neck far enough back. Don't be shy. People's heads will go back farther than you think when they are flaccid or paralyzed. Be gentle, but get the head into the position you need. Take control. Don't let the airway push you around.

[KatieC]

Thanks everyone for all the replies!

The thing I think I'm having the most problems with is finding the epiglottis. I know what it looks like, it's just that when I stick that blade in there, I have no idea where to go to get to it. I think I'm usually in not far enough, or trying to look too posterior. "Real people" anatomy is so variable. On the one I've gotten so far, I got in, I saw the cords, and put the tube in. If I can find the cords, I have no trouble getting the tube in there.

Asysin2leads, getting the head extended further is one of the things I've been working on. The 4-6 inches thing is good to know though. I'm tall for a girl (5'10"), but some CRNAs have been good about getting the bed up to my height for me to make it easier.

I've been using a Miller 2. Tried a Miller 3 on the mannequins but that seems to get me in way too far. I have no problem intubating the mannequins at all.

I tried 2 more times this past Friday and didn't get anything. There are just so few opportunities to even get anything. Those 2 attempts were during the course of an 8 hour day spent at the OR. We're competing with all the CRNA students and they get first dibs on the rooms because they're more "important" than just us EMT-I students (or so the anesthesia group thinks).

The 2 I tried Friday were both difficult again, according to the doctor. One was an 80-year-old man and he had the biggest, floppiest tongue I've ever seen. I never could get it out of the way.

Out of 8 people in our class, one has 3 tubes, one has 2, five of us have 1, and one person has 0. So I don't know if it's a combination of lack of opportunity or instructor methods or what.

I'm going back on Tuesday so we'll see what happens then.

[Dustdevil]

The thing I think I'm having the most problems with is finding the epiglottis. I know what it looks like, it's just that when I stick that blade in there, I have no idea where to go to get to it. I think I'm usually in not far enough, or trying to look too posterior.

A frequent problem with the use of the Miller is exactly what you are seeing. People have a tendancy to go in too far, yet still think they aren't deep enough and adjust in the wrong direction. But the beauty of the Miller blade is that you don't have to be as careful about where you insert. Go deep, then slowly pull back until you visualise the cords, and voila! Conversely, with the Mac, you have to be in the right place from the beginning, or else end up doing a lot of back-and-forth positioning.

I'd stick with the #3 on most patients (if not a #4), then just go with the above technique. The bigger blade tends to keep more tongue out of your way, and it also gives you more blade to use should you end up having to use it Mac style in a pinch.

[sledogg1]

http://www.healthsystem.virginia.edu/Inter...oscopyVideo.cfm

Try this............

Chris

[medic82942003]

Make sure they are in sniffing position-practice makes perfect. Good Luck. know your landmarks.Cheers

[EmergencyMedicalTigger]

Remember what to look at what you're doing the whole time. I think a common mistake people make (I'm guilty of it) is they start to advance the blade and then start looking in the airway. Watch what your doing the entire time then you will have an easier time identifying landmarks and knowing how far in you've gone. On a side note, our service switched to the disposable fiber optic blades-so nice! It makes a huge difference and illuminates everything.

[VentMedic]

Good points EmergencyMedicalTigger.

I've also had students act like they were shooting a gun for the first time. Just as they are getting ready to intubate, they blink, close their eyes and hurry the process too quickly.

[Doczilla]

Try this "two hands, no tube" method: When approaching the patient with the laryngoscope, place your right hand on the occiput of the patient's head. Guide the head to line up the airway as you insert the laryngoscope and visualize the cords. Once you see them, let go of the head with your right hand and pick up the tube while you maintain the visualization with your left hand.

'zilla

[EMSm0nster]

I wished LA County let EMTs intubate. That would be so cool. =)

Practice makes perfect