intubation difficulties as a med student

[MaykoTayko]

Hey everyone! I'm a 4th year med student that's going into EM. I just finished taking a month long anesthesiology course and I'm a bit disappointed to say my intubation skills are pretty bad. I've learned a lot of the basics, such as how to bag-mask effectively, placing IVs, RSI, etc, but when it comes to actual intubating my skills are so-so (~30-40% success rate out of like 15-20 attempts).

Is this a problem? Do I need to come into intern year knowing how to intubate well? Is this normal? I don't want to "never get the hang of it" and ruin my career....

Sorry for the minor freak out, I just don't have too many people I can talk to about this, and I'm a bit nervous. Thanks everyone!

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[gman33]

Most people are terrible when they first start.
A portion of this is the way most people are taught. Another part is that you are not used to looking at the anatomy.

Check out rich levitans videos.
He has a lot of great info.

 

[goodoldalky]

You'll be pretty mediocre until you get a hundred or two under your belt. It's normal.

 

[RustedFox]

Learning how to properly "seat" the blade in the vallecula is KEY.

 

[b-real]

Hopefully you're using a Mac blade as a beginner; it makes things much easier. Also, a common problem is that the blade is initially advanced too far. If you just see tissue and nothing else, slowly pull back, and the epiglottis will pop into view. Don't worry, my first intubation, my hands were so shaky the anesthesiologist I was with was panicking! As with all things, it gets easier with more experience.

 

[cbrons]

Hopefully you're using a Mac blade as a beginner; it makes things much easier. Also, a common problem is that the blade is initially advanced too far. If you just see tissue and nothing else, slowly pull back, and the epiglottis will pop into view. Don't worry, my first intubation, my hands were so shaky the anesthesiologist I was with was panicking! As with all things, it gets easier with more experience.

Part of the problem is when the anesthesiologist teaching you is a panicker.

I had this 70 year old anesthesiologist who didn't care at all. He very patiently showed me what to do and I just did it (smacking my hand away when I tried to "scissor" open the mouth - evidently some of the older guys hate that this is a standard technique).

You really have to just do a lot of them because it is not hard at all in the O.R. the vast majority of the time. In the E.R., every airway by definition is complicated because there isn't always time to evaluate their Mallanpati score or ask them what kind of intubation problems they may have had before.

 

[The White Coat Investor]

My first intubation was as an intern. I missed it. You'll be fine.

 

[DeadCactus]

All you're expected to come into intern year with is the ability to be taught...

 

[Cinclus]

I only got my first of three intubation attempts on my anesthesia rotation. First patient had very ideal anatomy for intubation, and I had first timer's luck. But yeah, I have had little experience with intubation of real live patients as a student. I am getting really good on those Laerdal models, though...

 

[alpinism]

Hopefully you're using a Mac blade as a beginner; it makes things much easier. Also, a common problem is that the blade is initially advanced too far. If you just see tissue and nothing else, slowly pull back, and the epiglottis will pop into view. Don't worry, my first intubation, my hands were so shaky the anesthesiologist I was with was panicking! As with all things, it gets easier with more experience.

Truth.

Epiglottoscopy FTW.

Everything you need to know about ED intubations:

http://emcrit.org/wp-content/uploads/2012/04/levitan-handout.pdf

 

[Fox800]

See if you can check out the Airway Cam book (Levitan authored it). That was awesome and really helped a ton when I was learning to intubate as a paramedic. Might be able to get it at your med school library.

 

[EM4life]

Part of it is that as a medical student, you get a try and as soon as you don't get it, someone else jumps in like a resident or the attending. When you are a resident, you eventually will be expected to manage the airway, no ifs or buts, you get to try twice or three times, you get tons of practice. When you become the person who's supposed to do it, you will learn it quickly. I sucked at LPs my intern year of residency but as soon as I was a second year and had no seen old resident to back me up, I just got it. You will do fine!

 

[EDandloveit]

Don't sweat it. You are going into emergency medicine to learn how to do things like that. Your program faculty will help to teach you. I can tell you that things are a little different in the ED than the OR and sometimes the distractions make it easier to get the job done. The most important thing I teach our residents is to learn how to bag the patient well. If you can do that you have all the time you need to get the tube.

 

[Angry Birds]

Hey everyone! I'm a 4th year med student that's going into EM. I just finished taking a month long anesthesiology course and I'm a bit disappointed to say my intubation skills are pretty bad. I've learned a lot of the basics, such as how to bag-mask effectively, placing IVs, RSI, etc, but when it comes to actual intubating my skills are so-so (~30-40% success rate out of like 15-20 attempts).

Is this a problem? Do I need to come into intern year knowing how to intubate well? Is this normal? I don't want to "never get the hang of it" and ruin my career....

Sorry for the minor freak out, I just don't have too many people I can talk to about this, and I'm a bit nervous. Thanks everyone!

I'd say you are ahead of the game with that experience and a 30-40% success rate as a medical student.

 

[filhodeinferno]

Learning how to properly "seat" the blade in the vallecula is KEY.

This was the turning point for me. Once I got this down, I feel like I never miss.

To address the OP, my first intubation didn't even happen until I was an intern on my anesthesia rotation, so I wouldn't sweat it.

 

[dchristismi]

Me either. Like, spring of my intern year.

Having a calm instructor also helps. I will never forget the pediatric anesthesiologist who made me reintubate a kid 3 times. As soon as I'd get it, he'd snatch it back out and make me do it again. (and yes, kid's sats were fine. While it seemed like forever, it was probably 30 seconds.) The principle of the thing being to place the double lines of the tube right at the cords. "Do Not Intubate The Toes!")

Practice makes perfect. And this is something you will get a lot of practice with. Have faith.

 

[Cinematographer]

Bump.

I'm on my anesthesia rotation I have had a 0/3 success rate using the Mac blade. I'm able to visualize the epiglottis, visualize cords but somehow end up losing my view and/or can't get the damn ET tube to pass through (my aiming is off?). Wondering if anyone is familiar with resources that teach proper handling of the ET tube, proper insertion of the blade, etc. I have a decent understanding of the anatomy, so a resource on technique is what I am looking for.

I have been able to intubate successfully using the Glidescope, but have been incredibly frustrated by my unsuccessful direct laryngoscopy attempts.

 

[RustedFox]

Bump.

I'm on my anesthesia rotation I have had a 0/3 success rate using the Mac blade. I'm able to visualize the epiglottis, visualize cords but somehow end up losing my view and/or can't get the damn ET tube to pass through (my aiming is off?). Wondering if anyone is familiar with resources that teach proper handling of the ET tube, proper insertion of the blade, etc. I have a decent understanding of the anatomy, so a resource on technique is what I am looking for.

I have been able to intubate successfully using the Glidescope, but have been incredibly frustrated by my unsuccessful direct laryngoscopy attempts.

It's cool, esse.

Hold the tube way back near the free end. It's a rapier, not a battle axe. An elegant weapon... Not clumsy or random like a blaster.

Roll that sucker back and forth between your two fingers and thumb. That's how you advance it when it gets stuck.

SEAT the mac-blade in the vallecula. Snug and deep. In there like swimwear. If you tug forward and you lose the view... You're seated too shallow.

 

[Fox800]

It's cool, esse.

Hold the tube way back near the free end. It's a rapier, not a battle axe. An elegant weapon... Not clumsy or random like a blaster.

Roll that sucker back and forth between your two fingers and thumb. That's how you advance it when it gets stuck.

SEAT the mac-blade in the vallecula. Snug and deep. In there like swimwear. If you tug forward and you lose the view... You're seated too shallow.

Props for the Obi-Wan reference.

 

[mega_colon]

As someone else mentioned, EPIGLOTOSCOPY. Changed my life. Shoving the blade in, cranking it, pulling it back, shoving in again, pulling back.... no bueno. Insert the blade into the mouth and sweep the tongue, then slowly advance it forward until you see the epiglottis come into view. You can then pretty much guide/ watch the tip of the blade go into the vallecula. Has made intubating SO much easier for me, and I pretty much never bloody up an airway any more.

Just an MS3 but did a month of anesthesia.

The above is spot in advice, slowing down the insertion so you can really visualize where the blade seats makes intubating much easier. I also found that holding with my hand closer to the angle of the blade gave me more precision in advancing the blade and limited the chance I would crank down on teeth.

 

[shoal]

It addition Scott weingart tip, make your ett look like a hockey stick. That way when u advance it, you don't obscure your view. Ett will come from posterior to anterior view. Gl

Sent from my VS986 using Tapatalk

 

[The White Coat Investor]

An elegant weapon... Not clumsy or random like a blaster.

I had a funny experience with that scene recently. I was in a hunter safety class and they were showing a picture of Luke looking down the barrel of that lightsaber. See the picture here:

For some reason I'd never noticed that before. Then I realized why....it's not in the movie.

 

[exsanguination]

As someone else mentioned, EPIGLOTOSCOPY. Changed my life. Shoving the blade in, cranking it, pulling it back, shoving in again, pulling back.... no bueno. Insert the blade into the mouth and sweep the tongue, then slowly advance it forward until you see the epiglottis come into view. You can then pretty much guide/ watch the tip of the blade go into the vallecula. Has made intubating SO much easier for me, and I pretty much never bloody up an airway any more.

Once I truly understood what this meant... like actually using and doing it in practice and UNDERSTANDING the anatomy and how to manipulate it, my success rate JUMPED. It truly is a jedi master art, and I have so much respect for anesthesia these days, particularly during (more like after) those difficult airways.

 

[Daiphon]

It's cool, esse.

Hold the tube way back near the free end. It's a rapier, not a battle axe. An elegant weapon... Not clumsy or random like a blaster.

Roll that sucker back and forth between your two fingers and thumb. That's how you advance it when it gets stuck.

SEAT the mac-blade in the vallecula. Snug and deep. In there like swimwear. If you tug forward and you lose the view... You're seated too shallow.

Word.

One other thing to consider, and this is without the benefit of knowing where your tube is getting hung up, but once you have a good view, lock your wrist on the arm with the blade.

Sometimes the tube gets caught on the blade proximally, and since you are looking distally, you don't see it. There shouldn't be any rocking, just lifting.

And, sometimes the tip gets caught up just past cords, so second @RustedFox on the rolling maneuver. Also, add some lube like with the GS.

-d



Semper Brunneis Pallium

 

[blue0rchid]

You got 15-20 tubes as a med student? I have none. You will do fine. Leave some room for them to teach you something.

 

[Janders]

Good advice above.
Usually getting the view is the hard part, and then passing the tube is relatively easy (with DL, opposite is true with glidescope typically).

Additional tips-- if you can see cords but can't get the tube there, you can put the tip of the tube towards the back of the blade, and advance the tube holding the tip against the blade all the way down. Literally sliding it down the blade. This will get the tip of your tube to the end of the blade (though the geometry at that point might be meh). Alternatively, if you can see the cords its usually easy to slam a bougie between them... then you can slide your tube over.

 

[HooliganSnail]

Hey everyone! I'm a 4th year med student that's going into EM. I just finished taking a month long anesthesiology course and I'm a bit disappointed to say my intubation skills are pretty bad. I've learned a lot of the basics, such as how to bag-mask effectively, placing IVs, RSI, etc, but when it comes to actual intubating my skills are so-so (~30-40% success rate out of like 15-20 attempts).

Is this a problem? Do I need to come into intern year knowing how to intubate well? Is this normal? I don't want to "never get the hang of it" and ruin my career....

Sorry for the minor freak out, I just don't have too many people I can talk to about this, and I'm a bit nervous. Thanks everyone!

I never even tried to intubate a patient until I was an intern. You will learn just fine.

 

[Old_Mil]

...don't run out of vines to hang from. You don't fall into the alligator filled pit of iatrogenic cardiac arrest until you do.

 

[emergentmd]

Hey everyone! I'm a 4th year med student that's going into EM. I just finished taking a month long anesthesiology course and I'm a bit disappointed to say my intubation skills are pretty bad. I've learned a lot of the basics, such as how to bag-mask effectively, placing IVs, RSI, etc, but when it comes to actual intubating my skills are so-so (~30-40% success rate out of like 15-20 attempts).

Is this a problem? Do I need to come into intern year knowing how to intubate well? Is this normal? I don't want to "never get the hang of it" and ruin my career....

Sorry for the minor freak out, I just don't have too many people I can talk to about this, and I'm a bit nervous. Thanks everyone!

Choose one blade and get good at it. Most docs I know picks either the miller or Mac and can get it 99% of the time.

I always choose a Mac 4 blade thus never need to go bigger. A Miller has never helped me when the Mac failed.

 

[EskimoFriend13]

Im an intern with a slightly different problem. I find the epiglottis ok but it's the lift that's killing me. I have a really hard time lifting the cords into view. I do the up and away thing but it seems like it's way harder than it should be. I'm a small female and thought maybe it was because I'm not strong enough, but everyone says it shouldn't be strength. However a couple of times I used my right hand as well (I know... Bad form) and the cords popped into view which just confirmed my probably inaccurate assumption that strength was limiting me. My success rate during my anesthesia rotation was probably around 50% and that's with ideal conditions. Only one attempt in the ER so far and had to switch to glidescope (huge guy with massive neck). I'm just really frustrated at this because I absolutely love intubating (when I get it) and feel like I am just missing something. On top of that, had an opportunity in the OR today on another rotation and totally goosed the patient. Thought I saw the cords but evidently not... Feel like an idiot after the anesthesiologist asked if knew how to intubate and I said yes.

 

[MSmentor018]

that's what residency is for, to teach you. don't sweat it for now, you'll get the hang of it. baby steps man. I did an anesthesia rotation after I matched, they knew I was going into em so luckily they just let me go from room to room and practice. also during that time period they were hosting "the difficult airway course" which I got to attend for free!! if you're really worried, ask the program you matched in what type of resources they have. 24 hr lab you can practice? hang out in the ER? show up for skills lab? videos.....etc.

but seriously, enjoy the rest of your ms4 yr. it'll never happen again. have fun, good luck

 

[EskimoFriend13]

that's what residency is for, to teach you. don't sweat it for now, you'll get the hang of it. baby steps man. I did an anesthesia rotation after I matched, they knew I was going into em so luckily they just let me go from room to room and practice. also during that time period they were hosting "the difficult airway course" which I got to attend for free!! if you're really worried, ask the program you matched in what type of resources they have. 24 hr lab you can practice? hang out in the ER? show up for skills lab? videos.....etc.

but seriously, enjoy the rest of your ms4 yr. it'll never happen again. have fun, good luck

Not sure if you were responding to me, but I am now close to 3/4 through my intern year, hence the frustration.

 

[turkeyjerky]

Not sure if you were responding to me, but I am now close to 3/4 through my intern year, hence the frustration.

What type of blade are you using. A Mac 4 requires a much greater application of force than a smaller blade, so you should try switching t a 3 if that's the case.

 

[Zebra Hunter]

Im an intern with a slightly different problem. I find the epiglottis ok but it's the lift that's killing me. I have a really hard time lifting the cords into view. I do the up and away thing but it seems like it's way harder than it should be. I'm a small female and thought maybe it was because I'm not strong enough, but everyone says it shouldn't be strength. However a couple of times I used my right hand as well (I know... Bad form) and the cords popped into view which just confirmed my probably inaccurate assumption that strength was limiting me. My success rate during my anesthesia rotation was probably around 50% and that's with ideal conditions. Only one attempt in the ER so far and had to switch to glidescope (huge guy with massive neck). I'm just really frustrated at this because I absolutely love intubating (when I get it) and feel like I am just missing something. On top of that, had an opportunity in the OR today on another rotation and totally goosed the patient. Thought I saw the cords but evidently not... Feel like an idiot after the anesthesiologist asked if knew how to intubate and I said yes.

Its not just about finding the epiglottis, it's about getting it into the sweet spot. You need to be placing the edge of the laryngoscope right into the vallecula. I often slightly overshoot or undershoot the vallecula and get a terrible view, but as soon as I slightly pull back/forward, the cords come into view. You should also try using bimanual laryngoscopy. There are plenty of videos out there that teach you the basics.

 

[hoot504]

A couple of things unlocked intubation for me.

The first one is properly holding the blade. You should hold it at the crux between the handle and blade. When someone finally deigned to tell me this it gave me so much added control I was almost pissed no one had ever told me before (and that I was too thick to pick it up).

The second thing is how you insert the blade. Some people attempt a side approach where the blade is ~90 degrees to the airway when they're first entering the mouth, in a lame attempt to 'sweep the tongue'. IMO, this is no good. Insert the blade in the same orientation it will be when in the vallecula, by sneaking in over the tongue and gliding along the roof of the mouth. Once you're in the vallecula, the tongue is out of your way.

The third consideration is that I've found the arytenoids can very easily be mistaken for the epiglottis. If you're well seated in the vallecula, and pulling with a good amount of force but the 'epiglottis' ain't moving, squat down a bit and look more anterior, boom, there's the cords. What you thought was epiglottis was just good ol' arytenoids. I may be the only one with this problem, but I doubt it.

YMMV, but once someone shared these pearls with me, I have missed literally one tube out of ~30.

 

[EskimoFriend13]

I have been using exclusively MAC 3 when I do direct. Thanks for the advice guys. I just wish I had more time in the OR. I had 8 days of anesthesia and unfortunately there were both residents and CRNA students to compete with. I am worried about trying to learn on our less than ideal ER population.

 

[gman33]

Im an intern with a slightly different problem. I find the epiglottis ok but it's the lift that's killing me. I have a really hard time lifting the cords into view. I do the up and away thing but it seems like it's way harder than it should be. I'm a small female and thought maybe it was because I'm not strong enough, but everyone says it shouldn't be strength. However a couple of times I used my right hand as well (I know... Bad form) and the cords popped into view which just confirmed my probably inaccurate assumption that strength was limiting me. My success rate during my anesthesia rotation was probably around 50% and that's with ideal conditions. Only one attempt in the ER so far and had to switch to glidescope (huge guy with massive neck). I'm just really frustrated at this because I absolutely love intubating (when I get it) and feel like I am just missing something. On top of that, had an opportunity in the OR today on another rotation and totally goosed the patient. Thought I saw the cords but evidently not... Feel like an idiot after the anesthesiologist asked if knew how to intubate and I said yes.

I used to think strength was needed until I learned how to position the patient.
The blade should only be used to move the tongue and epiglottis, not to life the whole head.

Use something under the patient to get the ear in line with the sternal notch. I usually put a couple of towels next to me and use 1-2 rolled up. The towels do the lifting for me.

Learning out positioning was basically a lightbulb moment. Intubation became fairly easy for me after that time.

It is really a matter of knowledge and skill, very little strength involved.

Now if you don't do those things, you do need strength.

If you can't figure it out, try to take the rich levitan course.

I can't recommend that enough.

 

[Cinematographer]

Just wanted to bump this thread because there is some genuinely good advice here. Killed it on my anesthesia rotation after a lackluster start (see post quoted by @RustedFox). These were my stats by the end of it (kept track of it just for fun):

• Total of 37 intubations: 32 by direct laryngoscopy (27/32 successful) plus 5 by GlideScope (5/5)
• 8 out of 37 were pediatric airways (ages 3 to 9)
• Used Mac blade ~80% of the time; got to use the Miller on the last week and thought it was great
• 17 LMAs placed. Accidentally displaced one of them while hooking it to the anesthesia machine
• No teeth broken (I did bruise the lips on a few of them though)

Overall a fun rotation, and one that I am 100% glad to have taken before residency.