Advice From One Anesthesiologist To Another

[Gern Blansten]

1st stage of intubation is laryngoscopy, getting that view of the cords
2nd stage of intubation is when the PVC passes cords (which is more stimulating)

3rd stage is delivery of the stylet.

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[coffeebythelake]

3rd stage is delivery of the stylet.

hahaha ok? do you force your stylet past the vocal cords?

 

[deleted126335]

3rd stage is delivery of the stylet.

Fourth stage is egress of the anesthesiologist from the OR as soon as the correct delivery of the tube has been confirmed.

 

[Gern Blansten]

hahaha ok? do you force your stylet past the vocal cords?

Was going to say placenta but opted for stylet to make the joke a little more obscure.

 

[dabears505]

I’m the junior guy in my group- 3ish months out from training. I like to think I was well trained over six years, but still try and remain open to advice and guidance. I’ve also been really pleasantly surprised at the old-timers who are super interested to see and hear about new approaches to old problems.

Sounds hokey, but the longer you can keep the learner mindset, the better.

6 years?

 

[coffeebythelake]

Was going to say placenta but opted for stylet to make the joke a little more obscure.

oh ok... didn't see or catch that reference since it was completely non sequitur

 

[abolt18]

6 years?

@Nivens did cardiac and critical care fellowships, so yes, 6 years.

 

[GassYous]

6 years?

He got left back once or twice

 

[coffeebythelake]

Fourth stage is egress of the anesthesiologist from the OR as soon as the correct delivery of the tube has been confirmed.

Don't forget to turn on the sevo. Don't do it WashU style.

 

[abolt18]

Don't forget to turn on the sevo. Don't do it WashU style.

Ouch. Too soon.

 

[Drwine]

The Miller and MAC are not meant to be used with exactly the same technique. When I see trainees try to use both with exactly the same approach I call it out. Before I let a new trainee attempt using a Miller blade, I tell the story of "wax on, wax off" in the Karate Kid. I then tell them I am giving them a snow shovel and tell them I am going to send them out to shovel the steps of every public building in town. I then draw the parallel of how they are going to shovel the tongue and epiglottis out of the way to see the larynx. I also point that none of our blades are a crowbar.

Going back to the original post, I realize that there are several ways to accomplish the same task and I keep my mouth shut. We had a former bellicose colleague who was convinced it was either his way or the wrong way. We used to make fun of him by playing the song Nobody Does it Better by Sheena Easton followed by You're No Good by Linda Ronstadt on YouTube in the break room after hearing of him criticizing someone.

 

[deleted875186]

Before I let a new trainee attempt using a Miller blade, I tell the story of "wax on, wax off" in the Karate Kid. I then tell them I am giving them a snow shovel and tell them I am going to send them out to shovel the steps of every public building in town. I then draw the parallel of how they are going to shovel the tongue and epiglottis out of the way to see the larynx. I also point that none of our blades are a crowbar.

What? Karate kid …. Shoveling steps.

Just tell Them to extend the head more, and inch past the epiglottis.

 

[Arch Guillotti]

Nobody Does it Better by Sheena Easton

Carly Simon actually

 

[nimbus]

Carly Simon actually

Right! Sheena Easton did another James Bond song, “For Your Eyes Only”.

 

[Drwine]

My mistake.

 

[narcusprince]

Hung like a 5 miller… If MACs are so much better. Why do ENT rigid bronchs look like Miller blades? I don’t use the miller blade often. Its DL with mac hand me the tube or bougie, fail then videolarygoscopy.

 

[deleted875186]

Hung like a 5 miller… If MACs are so much better. Why do ENT rigid bronchs look like Miller blades? I don’t use the miller blade often. Its DL with mac hand me the tube or bougie, fail then videolarygoscopy.

People say this, but it’s only because their instruments need a straight path to the cords, doesn’t mean it always gets a better view, although I do think it is a superior blade if DL was all you had ….

 

[jwk]

Mac3 about 95%, Mac4 about 5%, Miller about 2x/yr.

According to my old attendings (40+ years ago) anyone can muscle a tube in with a Miller blade (just like an ENT). It takes skill and finesse to use a Mac blade. Never seen anything that would change my opinion in 4 decades. Oh - and the Miller was always considered the "nurse blade"

 

[Mehd School]

Love how this nonsense turned into another mac vs. miller discussion.

I was 100% mac until I started doing peds then realized how much better I like the miller blades. You know all those old timers with the enormous, floppy epiglottis that you lift up high with the mac but can't still see around it? Not me. I like the blade that completely eliminates that variable from the equation.

 

[FiO2@21]

I use MAC, even with young kids. When a peds attending made me use a miller blade I still stuck it in the vallecula, nobody was the wiser.

 

[woopedazz]

An old mate absolutely styled on me the other day by pulling out a MAC3 for a prem neonate. I'm convinced, there's nothing it can't do

 

[pastafan]

The original IV Mac 3.5 was my instrument of choice. If needed, the Rusch gum bougie would do the trick. It was a tragedy when they stopped importing them to the US and the IV Mac blade was modified.

​

 

[Mehd School]

The original IV Mac 3.5 was my instrument of choice. If needed, the Rusch gum bougie would do the trick. It was a tragedy when they stopped importing them to the US and the IV Mac blade was modified.

​

We still have mac 3.5's

 

[GassYous]

The original IV Mac 3.5 was my instrument of choice. If needed, the Rusch gum bougie would do the trick. It was a tragedy when they stopped importing them to the US and the IV Mac blade was modified.

​

I used a mac 3.5 yesterday

 

[IMGASMD]

I used a Miller 4 once.

 

[pgg]

Next up, chili: beans or no beans?

 

[nimbus]

I used a Miller 4 once.

I saw a Mil3 once.

 

[VisionaryTics]

Hung like a 5 miller… If MACs are so much better. Why do ENT rigid bronchs look like Miller blades? I don’t use the miller blade often. Its DL with mac hand me the tube or bougie, fail then videolarygoscopy.

We do actually have a laryngoscope that is used like a Macintosh (Lindholm). It's used identically with pressure in the vallecula on the hyoepiglottic ligament. The advantage of the Lindholm is that doesn't distort the natural anatomy of the supraglottis or glottis, so it's useful for things like supraglottoplasties or vocal fold injections.

Lindholm:

That being said, our most common difficult airway scope is a straight, narrow blade (Hollinger anterior commissure scope). It is great at slipping around tumors, large tongues, narrow mandibles, edema, small mouth openings, etc. It is advanced past the epiglottis and can probably give a better view than any non-video laryngoscope in an anterior larynx.

Hollinger:

All things considered, anybody who does a lot of airway work needs a lot of tools in their toolbelt. In the ENT world, there is no "one size fits all" laryngoscope (the Dedo is a happy compromise between a lot of factors which is why it's our most commonly used scope).

 

[nimbus]

We do actually have a laryngoscope that is used like a Macintosh (Lindholm). It's used identically with pressure in the vallecula on the hyoepiglottic ligament. The advantage of the Lindholm is that doesn't distort the natural anatomy of the supraglottis or glottis, so it's useful for things like supraglottoplasties or vocal fold injections.

Lindholm:
View attachment 345882

That being said, our most common difficult airway scope is a straight, narrow blade (Hollinger anterior commissure scope). It is great at slipping around tumors, large tongues, narrow mandibles, edema, small mouth openings, etc. It is advanced past the epiglottis and can probably give a better view than any non-video laryngoscope in an anterior larynx.

Hollinger:
View attachment 345884

All things considered, anybody who does a lot of airway work needs a lot of tools in their toolbelt. In the ENT world, there is no "one size fits all" laryngoscope (the Dedo is a happy compromise between a lot of factors which is why it's our most commonly used scope).

Our ENTs use the glidescope a LOT these days.