Difficult intubation documentation?

[drchick331]

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We had a patient that came from Cleveland Clinic recently with some form identifying him as a difficult intubation during surgery. It looked like a standardized form letter containing personalized info regarding how they were able to intubate him. The staff I worked with were really thankful and are thinking of incorporating this type of documentation.

Has anyone else seen/used this type of form? Is it just more paperwork or is there some utility? Any thoughts appreciated.

Thanks!

 

[Noyac]

It's a very good idea and there is tremendous utility. We usually write a long post-op note describing the event and what worked an didn't work, then try to give a copy to the pt. We will be doing this with a pt we had last friday night, hopefully.

 

[fastosprintini]

that's considered a standard and extremely helpful for subsequent anesthetics, we provide a letter that mentions the intubation attempts , the kind of blades that were used, the views they provided and whether we used fiberoptics (flexible/bullard/mcgrath). most important for me is if the patient was an easy mask ventilation or not...
just my $0.02 , fasto

 

[excalibur]

of course you document everything on the intraop record, and that can be visible for future surgeries at that institution...but what if guy goes somewhere else...

apparently, i have been told that at our institution, there is such a form in our dept that we fill out when we encounter an unanticipated difficult intubation. We then give the pt a copy, so he can demonstrate this to anesthesiologists on future surgeries, particularly if he is going to other hospitals...just like what happened with the OP's pt.

 

[jennyboo]

I thought this was standard practice across all institutions. However, like yours, ours doesn't have standardized forms (although we probably should). I personally document the following details:

- mask?
- blades/techniques attempted & corresponding views
- LMA, if applicable
- how airway was ultimately controlled
- any additional information or tips for next time

I "store" the information in three different places:
1) Anesthesia record.

2) Letter to the patient that contains the details, PLUS instructions to bring this every time they have elective surgery, colonoscopy etc

3) Note entitled "Difficult Intubation" in the hospital's computer system, just in case patient shows up in the ER and some schmutz wants to push 20 of etomidate and 100 of sux

 

[Bertelman]

We include this info in our hospital's record system, but there is also an option to print the form, which we usually do.

jennyboo, I'd be surprised if that schmutz in the ER checks the medical record prior to tubing the guy in acute respiratory distress.

 

[Dejavu]

We do the letter to the pt thing and throw in a pamphlet on getting a Med-a-lert (sp?) bracelet.

 

[cchoukal]

we do the letter and our new EMR has a place to list it as an alert.

 

[jacksonrees]

As an Emergency Nurse, with special interest in management of difficult airways, at a tertiary academic center, may I say please document prior experience in managing the patient's difficult airway in as many places as possible and try to insist upon a Medic-Alert ID (the only comprehensive emergency medical identification system!). Patients simply don't remember this detail when stressed because they are focused on the next breath, and not planning forward towards potential intubation as we are. Few patients are prescient when in crisis. It takes medical training or a memory of a "really bad scare" before to be so mindful. Patients who were sedated or anesthetized during their experience may not understand how many beads of sweat you had that day.

Having some useful documentation readily available in the EMR or patient-brought letter (don't count on it🙁), or otherwise retrievable (Medic-Alert👍) will be great in planning and calling the cavalry before any crisis. Remember, too, Medic-Alert is also useful to EMS, even before the patient reaches "the schmutzes in the ED."😳

All patients will be evaluated for difficulty of ventilation, bag ventilation, difficult laryngoscopy, and difficult intubation, as well as potential placement of rescue and alternative airways. We don't like to burn bridges, either. And, yes, controlling the airway will only be done when essential or for distress. Having a plan, and calling for help before disaster, are essential.

Thanks for reading a viewpoint from downstairs!

 

[ProRealDoc]

As an Emergency Nurse, with special interest in management of difficult airways, at a tertiary academic center, may I say please document prior experience in managing the patient's difficult airway in as many places as possible and try to insist upon aMedic-Alert ID (the only comprehensive emergency medical identification system!). Patients simply don't remember this detail when stressed because they are focused on the next breath, and not planning forward towards potential intubation as we are. Few patients are prescient when in crisis. It takes medical training or a memory of a "really bad scare" before to be so mindful. Patients who were sedated or anesthetized during their experience may not understand how many beads of sweat you had that day.

Having some useful documentation readily available in the EMR or patient-brought letter (don't count on it🙁), or otherwise retrievable (Medic-Alert👍) will be great in planning and calling the cavalry before any crisis. Remember, too, Medic-Alert is also useful to EMS, even before the patient reaches "the schmutzes in the ED."😳

All patients will be evaluated for difficulty of ventilation, bag ventilation, difficult laryngoscopy, and difficult intubation, as well as potential placement of rescue and alternative airways. We don't like to burn bridges, either. And, yes, controlling the airway will only be done when essential or for distress. Having a plan, and calling for help before disaster, are essential.

Thanks for reading a viewpoint from downstairs!

Are you a sales rep for medic alert? Are you actually managing the difficult airways that present to the ED at your institution?

 

[rsgillmd]

We had a patient that came from Cleveland Clinic recently with some form identifying him as a difficult intubation during surgery. It looked like a standardized form letter containing personalized info regarding how they were able to intubate him. The staff I worked with were really thankful and are thinking of incorporating this type of documentation.

Has anyone else seen/used this type of form? Is it just more paperwork or is there some utility? Any thoughts appreciated.

Thanks!

I did this once, when I was a CA-1, for a patient that was an unexpected difficult intubation. I wrote the information on an index card and cut it down to size so she could put it in her wallet.

When I was a CA-2 covering PACU, one of my colleagues brings up a patient and says she was an unexpected difficult intubation. The patient is awake and looks at me, and says "Oh yeah, I forgot to tell you. That guy (pointing to me) gave me a card that said I was a difficult intubation."

The point of the anecdote is to say that your efforts may not result in any good, but in your story thankfully it did. Anything you do can only help.

Someone else posted about a MedicAlert bracelet. I hadn't thought of that before. Now it's something I may suggest in the future.

 

[jacksonrees]

Are you a sales rep for medic alert? Are you actually managing the difficult airways that present to the ED at your institution?

No, I am not "a sales rep for medic alert." No conflict of interest {I did insist that my wife wear one for her adrenal insufficiency.}

However, "MedicAlert® is a nonprofit membership organization founded in 1956 with a mission to protect and save lives, is headquartered in the United States and has international affiliates in nine countries." It was founded by a physician who created the first ID band for his own daughter's medical problem. Widely recognized, any health professional in the world can make a free phone call for information to ID the patient, obtain family & physician contact data, and further specifics as to details of health and treatment, or advanced directives. They have had an "E-HealthKEY" flash drive upon which to keep files, (even, the video of the FOB!); it has now been translated into a web-based access system: MedicAlert Gold.

As an Emergency Nurse, I do not personally intubate in my institution. But, being a serious student of airway management has informed my practice, made me a more capable "well-trained assistant", and helped me deal with dynamic and dangerous situations in concert with the Emergency Physicians and Anesthesiology faculty, and to promote a better understanding by our other nurses and trainees. This forum has been a valuable locus of information and cases which I greatly enjoy.

Please remember that people do forget to mention, do lose their wallets and purses, or may be unconscious and cannot speak of their problems. As long as MedicAlert is worn, there will be helpful information available.