Do you do the next DL?

[Planktonmd]

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I would never use that as my first choice.

Actually, I would NEVER use a Mac 4, since I SUCK with that blade.

I have witnessed, however, 2 very seasoned clinicians, one MD, one CRNA, who use the Mac 4 as their EVERY DAY BLADE.

They use it EVERY DAY, ALL DAY.

This biz is a very difficult one, Plank, to place a wrong label on something.

Who are you to say its wrong if the tube is placed atraumatically, 99% of the time?

I agree its atypical.

Alotta readers would say my practice of performing CSE ONLY FOR LABOR ANALGESIA is atypical.

THERE IS NO SUCH THING AS A "WRONG" BLADE, PLANK.

Unless you miss alot/cause damage with "that blade".

Then, and only then, is it the wrong blade.

I bet you that even the most seasoned clinicians who use a mac 4 as their everyday blade would not try to intubate a little old lady who can barely open her mouth with this blade.
But I agree with you, in this business there are many personal styles and there is no absolute right or wrong, but In my humble opinion before you are allowed to adopt an unusual method as your personal style you should earn the right to have a personal style, which means you must be exceptionally good at using that method, if you are not then using it is simply wrong.

 

[jetproppilot]

I thought good lord why put that huge piece of metal in this poor LOL's mouth? This is not the first time that I have thought this to myself. Every time though I have kept my mouth shut because my opinion is as long as you can get from point A to point B safely I don't care how you do it. I don't care how you do it, just do it safely. Just like I don't try to dictate what anesthetic the CRNA uses, so long as the pt. stays comfortable. At this point I don't worry about costs but that may change in the future. The only time I have ever suggested someone try a different blade on a pt. was when a SRNA was about to intubare someone with a normal airway with a Miller 3. The thing was, I didn't say anything. I looked at the CRNA like 😱, he looked back at me like 🙄 and suggested the SRNA try a smaller blade.

Aside: the above bolded text wasnt there in Arch's original post.

I did it inadvertently thinking it was my post.

Anyway, Arch, as you know theres a BIG difference concerning blade selection when comparing a CRNA with 20 years experience to an SRNA.

I'll level with you here.

Not all clinicians, anesthesiologists/crnas/aa's are made equally.

I can accept that there'd be some dudes out there with 20 years that would need some guidance.....but the majority with that much experience can at least hold their own and be accountable for intubations with the exception of an extraordinarily difficult airway.

Heres some advice, Arch.

Working with a CRNA/AA with 20 years experience: Does he/she get 90% of airways regardless of blade selection?

Leave'em be. After they look twice and fail, say "Dude, I'm gonna takka look." Saying dudeimgonnatakkalook isnt pretentious, bossy, etc. At the same time it relays to the individual that you are in charge and its time for them to step aside.

Working with a CRNA/AA with 20 years experience that needs ALOTTA GUIDANCE?

This is rare.

Most people that suck at what they do move to another profession.

Assuming you've gotta sukky employee, thats good when things are easy but bad when things are bad,

thats where LEADERSHIP intervenes.

Doesnt mean you haffta be a d ick.

Means you haffta intervene much earlier with "Dude lemme takka look."

 

[Planktonmd]

Aside: the above bolded text wasnt there in Arch's original post.

I did it inadvertently thinking it was my post.

Anyway, Arch, as you know theres a BIG difference concerning blade selection when comparing a CRNA with 20 years experience to an SRNA.

I'll level with you here.

Not all clinicians, anesthesiologists/crnas/aa's are made equally.

I can accept that there'd be some dudes out there with 20 years that would need some guidance.....but the majority with that much experience can at least hold their own and be accountable for intubations with the exception of an extraordinarily difficult airway.

Heres some advice, Arch.

Working with a CRNA/AA with 20 years experience: Does he/she get 90% of airways regardless of blade selection?

Leave'em be. After they look twice and fail, say "Dude, I'm gonna takka look." Saying dudeimgonnatakkalook isnt pretentious, bossy, etc. At the same time it relays to the individual that you are in charge and its time for them to step aside.

Working with a CRNA/AA with 20 years experience that needs ALOTTA GUIDANCE?

This is rare.

Most people that suck at what they do move to another profession.

Assuming you've gotta sukky employee, thats good when things are easy but bad when things are bad,

thats where LEADERSHIP intervenes.

Doesnt mean you haffta be a d ick.

Means you haffta intervene much earlier with "Dude lemme takka look."

Now this is excellent advice.
👍

 

[jwk]

Working with a CRNA/AA with 20 years experience that needs ALOTTA GUIDANCE?

This is rare.

Most people that suck at what they do move to another profession.

Assuming you've gotta sukky employee, thats good when things are easy but bad when things are bad,

thats where LEADERSHIP intervenes.

Doesnt mean you haffta be a d ick.

Means you haffta intervene much earlier with "Dude lemme takka look."

Amazingly, about 10 years ago, we had a CRNA that just plain couldn't intubate worht a damn. She probably had 20 years experience at other places - but we let her go at the and of her 90-day probationary period. I'll bet 75% of her cases had to be intubated by the anesthesiologist.

Also around the same time, we had one we swore couldn't extubate. It was always a thrash - never smooth, lots of laryngospasms, lots of coughing, etc. This was about 15 years into my career and I had never, ever, seen a case of negative pressure pulmonary edema until this person happened along. That person is no longer in our employ either.

 

[jetproppilot]

I bet you that even the most seasoned clinicians who use a mac 4 as their everyday blade would not try to intubate a little old lady who can barely open her mouth with this blade.
But I agree with you, in this business there are many personal styles and there is no absolute right or wrong, but In my humble opinion before you are allowed to adopt an unusual method as your personal style you should earn the right to have a personal style, which means you must be exceptionally good at using that method, if you are not then using it is simply wrong.

I totally agree.

This is a LEARNING site, after all.

It'd be ridiculous to recommend a Mac 4 in this situation.

If I remember correctly, though, the OP said the CRNA was "fairly experienced."

Which relays to me that this dude probably yields a Mac 4 with The Force.

And later yet, Arch asks why he could be better than someone thats been doing this 20 years...

Further evidence that we're talking about a clinician thats selected said-blade because he's uhhhhhhh....good with da blade.

I agree with you, Plank, that its an atypical choice.

This is an internet forum so theres alotta assumptions.

So I'm picking up what you're putting down.

I still adhere to the fact that you've gotta be pretty sure in this biz before you say a particular approach to a procedure is flat-out WRONG, which is what you posted, that a Mac 4 is WRONG in this situation.

I'm not defending the Mac 4 choice, since frankly I agree. Its not typical.

This site, though, is full of people in training.

Its important for them to keep an open mind to all approaches, since ultimately the "right" approach to that intubation/a-line/interscalene/epidural/CSE/IJ/subclavian/et al is

THE ONE THAT WORKS.

That effectively cuts thru surrogate endpoints and effectively references

OUTCOME.

My message to med students/residents is KEEP AN OPEN MIND. BE A SPONGE OF ALL APPROACHES YOU SEE TO A PARTICULAR CLINICAL SETTING, REGARDLESS OF ACADEMIC "ACCEPTANCE".

Patient Outcome is your most important endpoint.

Sometimes that requires extrapolation beyond our literature, which is rich with SURROGATE ENDPOINT STUDIES THAT, ALTHOUGH THEY PROVE "THEIR POINT," THEY SOMEHOW LOSE THE SIGNIFICANCE OF PATIENT OUTCOME.

I seem to recall literature against propofol for parturient induction when GA is needed for a C section since fetal cord pH was low in this study...

said study therefore deduced, since fetal cord pH was low, that propofol was bad for induction of GA for a C section.

Looking further, though, astute clinicians realized fetal OUTCOME was no different.....so the SURROGATE ENDPOINT the researchers were using as an an endpoint in this study....... cord pH....was USELESS.....

PIKKIN' UP WHAT I'M PUTTIN' DOWN?

Studies are just that.....reflections of research.

Sometimes their results are groundbreaking.

Sometimes their results are unknowingly misleading.

Takes an astute clinician to sift thru the banter.

 

[Planktonmd]

Ok, let me correct my post then:
If you pick a MAC 4 as your first blade to intubate a little old lady and the immediate result is trauma to the lips and airway (which the OP said had happened) then I could say with confidence that you are probably not good with that blade and this makes your choice Wrong.
Also, If you belong to the overwhelming majority of clinicians and you are not extremely talented with a MAC 4 to a point that you can atraumatically intubate a little old lady who can barely open her mouth with that huge blade then I will say that your choice of this blade is wrong even if you have been in practice for 50 years.
Is that good enough?

 

[jetproppilot]

Ok, let me correct my post then:
If you pick a MAC 4 as your first blade to intubate a little old lady and the immediate result is trauma to the lips and airway (which the OP said had happened) then I could say with confidence that you are probably not good with that blade and this makes your choice Wrong.
Also, If you belong to the overwhelming majority of clinicians and you are not extremely talented with a MAC 4 to a point that you can atraumatically intubate a little old lady who can barely open her mouth with that huge blade then I will say that your choice of this blade is wrong even if you have been in practice for 50 years.
Is that good enough?

I've seen most of your posts, Plank.

I've reached some personal conclusions about you based on your posts.

I'm the kinda dude that isnt influenced by people when interacting with someone.

I let the person speak for themselves.

This time, though, along time ago, I couldda said to myself

Mil was right

and saved myself a buncha time and effort.

I DON'T LIKE YOU, DUDE.

You remind me of a nurse administrator.

Posts that try and secure a position.....(i.e. "ARE YOU A HUNDRED PERCENT SURE?"..... rather than to teach residents to KEEP AN OPEN MIND.

I believe you're a sound person, and a sound clinician.....my existence and opinion about you won't affect you.

We're just two different people with different opinions about how to influence residents.

 

[Planktonmd]

Well,
I am really sorry that you feel this way because I actually always liked your energy and your colorful style.
I always thought that you give this forum a part of yourself and you sincerely wanted to teach something.
That said, I also feel that it is important to have different opinions and points of view in any discussion because the world is not made of people that agree on everything and follow one school of thought.
If you found my input to this forum irritating or if I offended you or your friends in any way then I have to say that this was not my intention and that I will do my best to avoid triggering any bad feelings.
After all this is an internet forum and for me it was an informative and enjoyable experience that seems to be unfortunately reaching it's end.
peace.

 

[SleepIsGood]

Fellas-

I'm the lowly resident here, however, I must write this. You two are prominent anesthesiologists on this forum. Obviously, there are different view points. I'm sure you guys would probably get along just fine in the real world vs this 'virtual world'. All I have to say is have the differences in opinions, but try not to get personal with each other. No reason to knock each other out. We have bigger fish to fry and foes that are trying to divide us.👍

 

[jetproppilot]

Well,
I am really sorry that you feel this way because I actually always liked your energy and your colorful style.
I always thought that you give this forum a part of yourself and you sincerely wanted to teach something.
That said, I also feel that it is important to have different opinions and points of view in any discussion because the world is not made of people that agree on everything and follow one school of thought.
If you found my input to this forum irritating or if I offended you or your friends in any way then I have to say that this was not my intention and that I will do my best to avoid triggering any bad feelings.
After all this is an internet forum and for me it was an informative and enjoyable experience that seems to be unfortunately reaching it's end.
peace.

UHHHHH,

thats not my intent dude.

Like I said you are a strong person/clinician.

I just feel sometimes you go to ends length to prove some ridiculous point.....

when the point isnt really relevant.....

you're valuable here, Plank.

I just don't understand your posts sometimes.....like the DENTAL SCENERIO about whether or not to do it in an ASC.....seems you were endlessly arguing about nothing....when in fact it was simple.....then OP subsequently posts an OUTCOME post saying it WAS SIMPLE, and your subsequent post was "YEAH, BUT......"

I don't get it.

Thats not real life anesthesia.

Thats arguing for the sake of arguing.

 

[jetproppilot]

Fellas-

I'm the lowly resident here, however, I must write this. You two are prominent anesthesiologists on this forum. Obviously, there are different view points. I'm sure you guys would probably get along just fine in the real world vs this 'virtual world'. All I have to say is have the differences in opinions, but try not to get personal with each other. No reason to knock each other out. We have bigger fish to fry and foes that are trying to divide us.👍

Your post is noted and respected.👍

 

[huktonfonix]

My 2 cents....

In residency, I had attendings like both of you. Some were more particular about things than others, some let you loose with appropriate guidance. You know what, I learned from all of them. Both of you bring your invaluable experience and knowledge to this forum for which I was grateful for as a resident and continue to be grateful as an attending. Like JPP alluded to, you both have valuable viewpoints just differing styles. Plank is definitely more on the argumentative side, but sometimes that does make you think about the topic even if you dont agree with the argument. In other words, KEEP ON DOING WHAT YOU GUYS ARE DOING. Its what makes this forum great (in addition to the gun and alcohol posts)

 

[Arch Guillotti]

Fellas-

I'm the lowly resident here, however, I must write this. You two are prominent anesthesiologists on this forum. Obviously, there are different view points. I'm sure you guys would probably get along just fine in the real world vs this 'virtual world'. All I have to say is have the differences in opinions, but try not to get personal with each other. No reason to knock each other out. We have bigger fish to fry and foes that are trying to divide us.👍

Second that.

 

[jetproppilot]

Well,
I am really sorry that you feel this way because I actually always liked your energy and your colorful style.
I always thought that you give this forum a part of yourself and you sincerely wanted to teach something.
That said, I also feel that it is important to have different opinions and points of view in any discussion because the world is not made of people that agree on everything and follow one school of thought.
If you found my input to this forum irritating or if I offended you or your friends in any way then I have to say that this was not my intention and that I will do my best to avoid triggering any bad feelings.
After all this is an internet forum and for me it was an informative and enjoyable experience that seems to be unfortunately reaching it's end.
peace.

I respectfully request you cast aside your feelings here.

I respect your stance.

Let me remind you that there is NOT ONE influential person on planet earth who is LIKED BY EVERYONE.

You are influential.

You will not be liked by everyone.

And thats OK.

 

[proman]

Just because someone's been doing a job for 20+ years doesn't mean they've done it right or well. We shouldn't assume they are slick because they've been around the block. The Force is weak in some no matter what.

 

[Arch Guillotti]

Just because someone's been doing a job for 20+ years doesn't mean they've done it right or well. We shouldn't assume they are slick because they've been around the block. The Force is weak in some no matter what.

yeah I know, I guess I am going to start being a dickhole more often (even when it really isn't being a dickhole). I like to give everyone a fair chance though and I try not to be too much of the stereothypical type A control freak that I think we all secretly are

 

[SleepIsGood]

..... I try not to be too much of the stereothypical type A control freak that I think we all secretly are

shhhh why are you letting out the secret

 

[Bertelman]

I appreciate all the transparency, Jet and Plank, but maybe your discussion should be continued via PM. It's kind of awkward for the rest of us watching, like seeing your parents argue.

Bottom line, both of you are valuable to this forum. From a learning perspective, the more opinions we have the more we learn.

 

[ncdoc1974]

I work in an MD only practice...no CRNAs...so I am not too familiar with supervising except for a brief amount of time during residency...My question is this (something I've never understood about supervising CRNA's): One of the most critical times of the anesthetic is securing the airway...why leave this job to the nurse? After working by myself for a number of years without any real assistance available, I have moved to doing only one DL; If I cannot get the tube in, the only time I will do a second DL is if I REALLY think I can get it with a different blade or a bougie...Otherwise, no more DLs, and I immediately move to a Fastrach, Fiberoptic before the airway gets bloody from multiple DLs, a light wand, or my new favorite toy, the McGrath laryngoscope...I know what I see, and I know what I need to do to avoid harm to a patient...I think it would be very difficult to observe a CRNA flail and flail again trying to tell you what they can't see...If you are present for induction, WHY NOT just take the bull by the horns and just do it yourself? And if you can give me a good reason (which someone probably will try to do) then why not take over immediately after the CRNA has failed the first time? (and don't recite the difficult airway algorhythm about 2 DLs by the first provider followed by another DL by a second provider)

 

[jwk]

I work in an MD only practice...no CRNAs...so I am not too familiar with supervising except for a brief amount of time during residency...My question is this (something I've never understood about supervising CRNA's): One of the most critical times of the anesthetic is securing the airway...why leave this job to the nurse? After working by myself for a number of years without any real assistance available, I have moved to doing only one DL; If I cannot get the tube in, the only time I will do a second DL is if I REALLY think I can get it with a different blade or a bougie...Otherwise, no more DLs, and I immediately move to a Fastrach, Fiberoptic before the airway gets bloody from multiple DLs, a light wand, or my new favorite toy, the McGrath laryngoscope...I know what I see, and I know what I need to do to avoid harm to a patient...I think it would be very difficult to observe a CRNA flail and flail again trying to tell you what they can't see...If you are present for induction, WHY NOT just take the bull by the horns and just do it yourself? And if you can give me a good reason (which someone probably will try to do) then why not take over immediately after the CRNA has failed the first time? (and don't recite the difficult airway algorhythm about 2 DLs by the first provider followed by another DL by a second provider)

So who is your backup if you can't get the tube in? Is there always someone else available?

As I stated in my earlier post, I get humbled a couple times a year - the last time by a new attending who got the tube in on HIS 3rd attempt. The flip side of that is I get a couple tubes a year that one of my 36 attendings didn't get. Good skills, teamwork, and communication all around goes a long way towards reducing puckering of the providers.

 

[ncdoc1974]

So who is your backup if you can't get the tube in? Is there always someone else available?

As I stated in my earlier post, I get humbled a couple times a year - the last time by a new attending who got the tube in on HIS 3rd attempt. The flip side of that is I get a couple tubes a year that one of my 36 attendings didn't get. Good skills, teamwork, and communication all around goes a long way towards reducing puckering of the providers.

During the day, one of my partners MIGHT be available between cases, but usually not and after hours there is no one else available...So I guess typically there is no backup...This type of setup will make you be more conservative with your practice...I've gotten real good at awake oral fiberoptic intubations if I know the airway may be tough, or if they are morbidly obese...I will only paralyze a patient once I am SURE I can mask ventilate, I am pretty skilled with a variety of airway devices...and ultimately if I am unable to intubate a patient, I will wake them up and place the tube awake...As far as your new attending getting a tube on his 3rd attempt, I would NEVER do 3 DLs...the bloody factor is too much of a risk...laryngoscopes are great for most patients, however if it isn't working well the 1st time, instead of cranking on the patients neck, risking dental/lip/oropharyngeal trauma & blood, why not just bail out early, mask ventilate and move to any one of many fun airway devices that are made for folks who don't have airway anatomy favorable for a laryngoscope? If I can't get an airway easily with a laryngoscope I don't force the issue...I don't feel ashamed in my inability to tube a given patient with a laryngoscope...we have lots of other tools at our disposal for a reason...use them often! Again, they are also easier to use before the airway is swollen and bloody.

 

[KungPOWChicken]

ncdoc1974 you could have not said it better!!!!! Why let the crna traumatize the airway, give the patient a fat lip or use a fricking mac 4 in an old grandma. The first step in assessing an airway is making a logical choice in your instrument before you do a dl. As far as i'm concerned a fat lip is a failed intubation because when the patient wakes up they notice that. It doesn't go away in a day. Why not do the dl if your standing there because ultimately the patient should get the best care possible.

 

[jwk]

ncdoc1974 you could have not said it better!!!!! Why let the crna traumatize the airway, give the patient a fat lip or use a fricking mac 4 in an old grandma. The first step in assessing an airway is making a logical choice in your instrument before you do a dl. As far as i'm concerned a fat lip is a failed intubation because when the patient wakes up they notice that. It doesn't go away in a day. Why not do the dl if your standing there because ultimately the patient should get the best care possible.

The last two lacerated lips I've seen - one by a senior anesthesiology attending at Emory on my brother-in-law, the other by an anesthesia-CCM attending on my own father. Explain those to me KPC.

Guess who I'd prefer to intubate someone in my family? Someone who does it EVERY SINGLE DAY, rather than a few times a year, regardless of the initials behind their name, and without a HUGE ego chip on their shoulder.

 

[Arch Guillotti]

Well live and learn. I'll likely approach these sorta things somemwhat differently in the future. Almost definitely no more than 2 DL's for anyone, and for some it may be 1 strike and you are out.

Maybe I should just shove the nurse out of the way and do them all myself

The thing about this situation that confounded things was the fact that (other than using the "wrong" blades) the CRNA is pretty darn good at his job and doesn't have a chip on his shoulder or an attitude and I enjoy working with him. He's also a decent laryngoscopist. The reality of the situation is that while it is easy to "damn the torpedos" and be a hero every time on an anonymous internet bulletin board, there are other forces at work in the "real world".

 

[jetproppilot]

Well live and learn. I'll likely approach these sorta things somemwhat differently in the future. Almost definitely no more than 2 DL's for anyone, and for some it may be 1 strike and you are out.

Maybe I should just shove the nurse out of the way and do them all myself

The thing about this situation that confounded things was the fact that (other than using the "wrong" blades) the CRNA is pretty darn good at his job and doesn't have a chip on his shoulder or an attitude and I enjoy working with him. He's also a decent laryngoscopist. The reality of the situation is that while it is easy to "damn the torpedos" and be a hero every time on an anonymous internet bulletin board, there are other forces at work in the "real world".

.

 

[ncdoc1974]

Well live and learn. I'll likely approach these sorta things somemwhat differently in the future. Almost definitely no more than 2 DL's for anyone, and for some it may be 1 strike and you are out.

Maybe I should just shove the nurse out of the way and do them all myself

The thing about this situation that confounded things was the fact that (other than using the "wrong" blades) the CRNA is pretty darn good at his job and doesn't have a chip on his shoulder or an attitude and I enjoy working with him. He's also a decent laryngoscopist. The reality of the situation is that while it is easy to "damn the torpedos" and be a hero every time on an anonymous internet bulletin board, there are other forces at work in the "real world".

1) I do not want a "decent" laryngoscopist for my intubation, I want an excellent one

2)You said "The reality of the situation is that while it is easy to "damn the torpedos" and be a hero every time on an anonymous internet bulletin board, there are other forces at work in the "real world"---What do you mean by this statement? As I stated before I am in an MD only pracitce and I really am curious why the nurse does the intubations instead of the anesthesiologist in a supervision model...I am not trying to poke at anyone, I just have never understood the reasoning behind this practice...when you say "forces at work in the real world" is some sort of power struggle issue or what? I really am ignorant when it comes to this sort of dynamic...

 

[thegasman]

crna usually gets one look with me if they can't see - then it is my turn and if I can't see it is glidescope or fastrach time. I try to do at least one of my own intubations a day, and I have found that I am still better than most of the "laryngoscopists that do it every day". There are a few crnas who are probably as good or better than me however, but this is not the norm.

 

[Arch Guillotti]

1) I do not want a "decent" laryngoscopist for my intubation, I want an excellent one

2)You said "The reality of the situation is that while it is easy to "damn the torpedos" and be a hero every time on an anonymous internet bulletin board, there are other forces at work in the "real world"---What do you mean by this statement? As I stated before I am in an MD only pracitce and I really am curious why the nurse does the intubations instead of the anesthesiologist in a supervision model...I am not trying to poke at anyone, I just have never understood the reasoning behind this practice...when you say "forces at work in the real world" is some sort of power struggle issue or what? I really am ignorant when it comes to this sort of dynamic...

Re point #1: point taken.

Re point#2: I try not to get worked up when everything isn't exactly a slam dunk. There is somewhat of a "power struggle" here. The CRNA's would go ape**** if the doc did all the tubes. One thing about anesthesia is that during residency you are frequently alone during procedures (other than with the attending). Now that I am supervising I get to watch a lot of folks perform procedures. I know that I am an excellent laryngoscopist😀 and now I get to compare everyone else to the standard that I expect. Let me say it again, the attending learning curve is just as steep as the resident curve (at least for now).

 

[Arch Guillotti]

crna usually gets one look with me if they can't see - then it is my turn and if I can't see it is glidescope or fastrach time. I try to do at least one of my own intubations a day, and I have found that I am still better than most of the "laryngoscopists that do it every day". There are a few crnas who are probably as good or better than me however, but this is not the norm.

Agree w/all that. From now on I am gonna be a "one and done" type of guy.

DAMN THE TORPEDOES!

Locking thread because I am tired of talking about this.