Improving DL skills

[nacholibre]

So I've finished my intern year and with the start of my PGY2 year, I'm starting to see the inside of an OR. I've been surprised by how I'm taking to some procedures that I assumed previously to be quite difficult. However, others that I once thought looked like easy surgeries are making me look like one of the 3 stooges.

I was most surprised by DLs. I'm a pretty big strong guy, but I've found myself sweating and fatiguing whilst my tiny female chief resident is gracefully having no problems. This makes me think, I'm not doing it right. There are only so many questions you can ask your attending without becoming annoying, so I wanted to poll you all on ways to become more effective and efficient with DLs.

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[DrBodacious]

Patients are highly variable with respect to how easy the exposure is. People describe tough patients have an "anterior larynx," but to be more descriptive, the big obstacles are the dentition and tongue (maxillary dentition, mandibular dentition, and the shape of the mandibular arch). With a narrow mandible and large tongue, it is hard to compress/get around the tongue to get the scope directed to the endolarynx. Scope selection is important. Sometimes, an anterior commisure scope is necessary to see the whole glottis. One of the main benefits of the anterior commisure scope is the body of the scope is so narrow that it slides between the tongue and the mandible easily (into the floor of mouth). The actual tip of the scope isn't much smaller than an OP.

For the tough exposures sometimes you have to come from the side a bit . This creates issues with everything wanting to tilt, especially if you are suspending. Ie you need to put towels under one side of the suspension bar.

 

[DrBodacious]

Another tip is that, unless it is a chip shot, "bumping" the head board up to get the patient in a sniffing position usually improves the access /view.

 

[ThePursuit]

I feel you. DL's were something I was not expecting to be as much of a challenge to become proficient in as they are when I started residency. When I struggle, I always try to take a step back and ask what things I'm doing to make it more difficult than necessary. Sometimes that helps. If an attending comes and gets better exposure for a suspension case etc, I always make sure I understand what they did differently.

 

[VisionaryTics]

Same here. Really struggling with DLs. I sweat and struggle and can barely see arytenoids, and then the chief steps in and makes one smooth motion to get a beautiful view of the cords. I feel like there's just something I'm missing (aside from experience).

 

[VisionaryTics]

Same here. Really struggling with DLs. I sweat and struggle and can barely see arytenoids, and then the chief steps in and makes one smooth motion to get a beautiful view of the cords. I feel like there's just something I'm missing (aside from experience).

Bump. Any advice from attendings/senior residents?

One of the reasons I'm frustrated is that I pretty much get no instruction on DLs. The senior residents aren't leaving big cases to help the PGY2 through a triple, and the attendings just usually want to crank through them because they have some huge head and neck case to follow. So I'm left with like a 30-second shot to try to get a view.

Essentially, I get held up at the same spot every time. I get past the epiglottis, have the epiglottis pressed against the superior aspect of my scope, I'm staring right at the ET tube and the posterior pharynx as well as the tops of the arytenoids, but I can't advance the scope. I try to lift, try to reposition the head with my other hand, but I probably get a view of the endolarynx 20% of the time. I'm deathly afraid to knock a tooth out, so I never crank my wrist, but I just have no idea how to consistently "make the turn" and see the endolarynx. I get caught struggling against the tube every time.

 

[Pir8DeacDoc]

Sometimes your view gets better when you actually suspend them. You won't necessarily see everything prior to the suspension part of the procedure.

 

[OtoHNS]

Bump. Any advice from attendings/senior residents?

One of the reasons I'm frustrated is that I pretty much get no instruction on DLs. The senior residents aren't leaving big cases to help the PGY2 through a triple, and the attendings just usually want to crank through them because they have some huge head and neck case to follow. So I'm left with like a 30-second shot to try to get a view.

Essentially, I get held up at the same spot every time. I get past the epiglottis, have the epiglottis pressed against the superior aspect of my scope, I'm staring right at the ET tube and the posterior pharynx as well as the tops of the arytenoids, but I can't advance the scope. I try to lift, try to reposition the head with my other hand, but I probably get a view of the endolarynx 20% of the time. I'm deathly afraid to knock a tooth out, so I never crank my wrist, but I just have no idea how to consistently "make the turn" and see the endolarynx. I get caught struggling against the tube every time.

Hard to say without watching you in person to see what you're doing. From what you're describing, it might be that you're not using the scope to move the tongue out of the way enough. Think of using a Mac blade on anesthesia to intubate the patient- you go along the side of the tongue and sweep it out of the way. You can do the same thing with our laryngoscopes to get more view anteriorly.

But really, it sounds like your attending are dropping the ball on this one. Perhaps they don't realize how much difficulty you are having. If I were you, I'd bring it up to your attending- yes they are in a hurry, but 2 minutes of observing you and giving some directed instruction will go much further than the guesses of people on here.

And don't sweat it too much, you'll figure it out. Everyone does eventually.

 

[neutropeniaboy]

I was never very good at performing DLs. I would always need to suspend people. This persisted despite several hundred DLs. I don't have to DL people anymore...