Economics of having a McGrath in every OR

[Arch Guillotti]

I've had a few instances where the tube seems to be in the airway but when I go to bag, no end tidal. I think I am not twisting the airway properly and getting caught on the arytenoids and the tube is just out of the cords.

You are in the goose.

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[GassYous]

You are in the goose.

Covid patient that needed a tube exchange because of a suspected torn cuff. Have repeated end tidal. disconnected tube, bougie in, felt resistance. Tube out, new tube in at 22. No end tidal. Emergently reintubated with glide.

Ludwig angina, 6.0 in. Repeated end tidal. TV are crappy so decide to try to exchange tube over bougie. Bougie in, felt resistance so took out the 6.0 over bougie and 7.0 over bougie. No end tidal.

I wonder if the cuff is not in or if I'm getting caught on arytenoids or if I'm just not in the trachea at all. But originally I was in without issues.

 

[nimbus]

What if their mouth is small? Glidescope plus DLT is pretty bulky.

So far it hasn’t been an issue. Sometimes I’ll stick the tube in the pharynx first, then put glidescope in. Often the tube tip is sitting just above cords.

 

[deleted162650]

I usually go with the blind digital technique for my DLTs.

 

[mdawarre]

Covid patient that needed a tube exchange because of a suspected torn cuff. Have repeated end tidal. disconnected tube, bougie in, felt resistance. Tube out, new tube in at 22. No end tidal. Emergently reintubated with glide.

Ludwig angina, 6.0 in. Repeated end tidal. TV are crappy so decide to try to exchange tube over bougie. Bougie in, felt resistance so took out the 6.0 over bougie and 7.0 over bougie. No end tidal.

I wonder if the cuff is not in or if I'm getting caught on arytenoids or if I'm just not in the trachea at all. But originally I was in without issues.

Bougie is not a tube changer. Not long enough.

 

[IMGASMD]

Bougie is not a tube changer. Not long enough.

How deep do you push the tube exchanger down?

 

[Arch Guillotti]

Bougie is not a tube changer. Not long enough.

Sure it is. How would it work when using it to intubate otherwise?

 

[drmwvr]

...I wonder if the cuff is not in or if I'm getting caught on arytenoids or if I'm just not in the trachea at all....

Corniculates...you're getting caught on the corniculates......

 

[mdawarre]

Sure it is. How would it work when using it to intubate otherwise?

railroading an ett over a bougie in the trachea is not the problem. the problem is removing an existing ett over a bougie and still maintaining control of the bougie. it is a device intended to facilitate tracheal intubation. not a tube changer.

 

[mdawarre]

How deep do you push the tube exchanger down?

i line up the cm marks on the tube changer to match the depth of the ett. also if you get in trouble (can't railroad the ett), you can always ventilate through the tube changer to buy some time. side note- i think it's almost always better to get a view of the cords (after suctioning, pt on 100%, and paralyzed), remove the ett under direct visualization and just reintubate. we've had multiple complications related to tube changes gone wrong.

 

[Arch Guillotti]

i line up the cm marks on the tube changer to match the depth of the ett. also if you get in trouble (can't railroad the ett), you can always ventilate through the tube changer to buy some time. side note- i think it's almost always better to get a view of the cords (after suctioning, pt on 100%, and paralyzed), remove the ett under direct visualization and just reintubate. we've had multiple complications related to tube changes gone wrong.

I agree. Glidescope with real tube exchanger.

 

[Arch Guillotti]

railroading an ett over a bougie in the trachea is not the problem. the problem is removing an existing ett over a bougie and still maintaining control of the bougie. it is a device intended to facilitate tracheal intubation. not a tube changer.

It can be done. Not as good as a real tube exchanger but it can be done.

 

[mdawarre]

It can be done. Not as good as a real tube exchanger but it can be done.

yes agree arch

 

[GassYous]

Yea I should have checked the tube as it goes in. I had the bougie right there because it's in every airway box and OR. But I will have a tube exchanger handy next time. Thanks guys.

Good point about corniculates, my mistake.

 

[woopedazz]

Covid patient that needed a tube exchange because of a suspected torn cuff. Have repeated end tidal. disconnected tube, bougie in, felt resistance. Tube out, new tube in at 22. No end tidal. Emergently reintubated with glide.

Cuff probably wasn't leaking. Cuff was probably on the wrong side of the cords; with the distal tube still in situ. Bougie getting caught on the way in/not advancing past 22 = you surely can't be in, right?

 

[anaesthetic]

.

 

[GassYous]

Cuff probably wasn't leaking. Cuff was probably on the wrong side of the cords; with the distal tube still in situ. Bougie getting caught on the way in/not advancing past 22 = you surely can't be in, right?

Correct about the cuff. One time after that patient I took a look and noticed that the cuff was herniating above the cords and was enormous. Suspected that they were getting a lot of calls about a leak and kept putting air in the cuff instead of checking it.

 

[mdawarre]

Correct about the cuff. One time after that patient I took a look and noticed that the cuff was herniating above the cords and was enormous. Suspected that they were getting a lot of calls about a leak and kept putting air in the cuff instead of checking it.

right? it's never a cuff leak.

 

[Velefunt]

I feel like a curmudgeonly attending every time I tell my residents they're not allowed to use the McGrath. Their skills with a DL are absolutely terrible and their ability to troubleshoot is severely undermined.

On the other hand, this technology is only getting cheaper, so it is feasible that in 5-10 years DL isn't used at all.

If they plan to cover any ASC's in PP, then they'd better learn how to DL and troubleshoot, because everything is overhead. They'll be quickly dis-invited to credential at the ASC if they require video laryngoscopy for all patients.

I'd rather save that overhead for the occasional vial of ephedrine I might want to crack.

It's ridiculous, but it's PP and ASC's located in the lowest of payor mixes.

 

[propadope]

One thing your attendings may have overlooked is it's a good idea to have a few different types of VLs available at any one time.

With the COVID outbreak Medtronic stopped exporting battery packs to many Australian hospitals as the demand was too high in America/Europe. Our hospital couldn't place any orders and couldn't compete with the scalpers on eBay after a few weeks --> we ended up having 20+ McGrath's completely unusable. That's why we had to source some old Pentax-AWS scopes out of some storage/surplas warehouse on the other side of the country... This at a 800+ bed hospital.

I'd push for 2 different VLs minimum; never put all your eggs in one basket. Especially a propriety basket with a timer.

Are you able to get McGrath batteries now? I ordered one a month ago and its been on back order. Ended up picking up a couple on ebay. I only have one scope. BTW the batteries are proprietary but they can be hacked. Ive been discarding used ones but now I will be saving them just in case

 

[IMGASMD]

Are you able to get McGrath batteries now? I ordered one a month ago and its been on back order. Ended up picking up a couple on ebay. I only have one scope. BTW the batteries are proprietary but they can be hacked. Ive been discarding used ones but now I will be saving them just in case

There is a YouTube video somewhere that teach you how to hack it, floating around. I haven’t tried it, but when you’re in a pinch, I guess it’s better than nothing.

The word on the street was that the factory is actually in Wuhan, China.

I am surprised, it’s not in a conspiracy theory of its own.

 

[propadope]

There is a YouTube video somewhere that teach you how to hack it, floating around. I haven’t tried it, but when you’re in a pinch, I guess it’s better than nothing.

The word on the street was that the factory is actually in Wuhan, China.

I am surprised, it’s not in a conspiracy theory of its own.

Yes Ive seen the video and I will be trying the hack once my battery dies

 

[pgg]

So apparently you can’t even yell at them anymore when they screw up. It hurts their feelings. And they really try to act like they are your equal.

Yelling is the last refuge of an incompetent teacher, and a sign of someone whose composure has been misplaced. The only time anesthesiologists should ever raise their voices is to be heard in a noisy room.

I have of course learned things from people who've yelled at me. More than they intended to teach, actually. The best thing about some teachers is how they demonstrate what not to do or how not to behave.

 

[jw3600]

are you maintaining direct visualization the whole time (2 man operation), or do you remove the blade and railroad the tube over the bougie blindly?

Any thoughts on this?
-PGY3 EM

 

[chocomorsel]

Yelling is the last refuge of an incompetent teacher, and a sign of someone whose composure has been misplaced. The only time anesthesiologists should ever raise their voices is to be heard in a noisy room.

I have of course learned things from people who've yelled at me. More than they intended to teach, actually. The best thing about some teachers is how they demonstrate what not to do or how not to behave.

Well guess I must be incompetent then.
Yup that must be it.
Not a reaction to seeing so many people die from premature intubations by the inexperienced.
Nope, I must be incompetent.

 

[Katheudontas parateroumen]

Any thoughts on this?
-PGY3 EM

Depends on what’s available. If it’s questionable airway, then I try to visualize while exchanging. If it’s routine I just use a tube exchanger. I haven’t used the boogie often to do exchanges to see if there’s a real difference to an Antree/cook. i imagine it being more difficult as the bougie is more rigid or maybe no difference? The hold up to exchanging is usually the R arytenoid as the bevel is facing the left with the tip of tube hitting up against it and turning the tube ccw moves the bevel from getting caught. Here's a couple interesting article all about mishaps in tube exchanging and FOI tubes getting caught too.

Fiberoptic Intubation: Troubles with the “Tube”?

To the Editor:—The article by Dr. Kristensen highlights a problem often faced by practitioners when using a fiberoptic scope to intubate the trachea, i.e. , resistance to passage of the endotracheal tube. 1This is usually attributed to the endotracheal tube being caught on structures of the...

pubs.asahq.org

Difficulty in advancing a tracheal tube over a ®breoptic bronchoscope: incidence, causes and solutions T. Asai* and K. Shingu Department of Anaesthesiology, Kansai Medical University, 10-15 Fumizono-cho, Moriguchi City, Osaka 570±8507, Japan

 

[jw3600]

Depends on what’s available. If it’s questionable airway, then I try to visualize while exchanging. If it’s routine I just use a tube exchanger. I haven’t used the boogie often to do exchanges to see if there’s a real difference to an Antree/cook. i imagine it being more difficult as the bougie is more rigid or maybe no difference? The hold up to exchanging is usually the R arytenoid as the bevel is facing the left with the tip of tube hitting up against it and turning the tube ccw moves the bevel from getting caught. Here's a couple interesting article all about mishaps in tube exchanging and FOI tubes getting caught too.

Fiberoptic Intubation: Troubles with the “Tube”?

To the Editor:—The article by Dr. Kristensen highlights a problem often faced by practitioners when using a fiberoptic scope to intubate the trachea, i.e. , resistance to passage of the endotracheal tube. 1This is usually attributed to the endotracheal tube being caught on structures of the...

pubs.asahq.org

Difficulty in advancing a tracheal tube over a ®breoptic bronchoscope: incidence, causes and solutions T. Asai* and K. Shingu Department of Anaesthesiology, Kansai Medical University, 10-15 Fumizono-cho, Moriguchi City, Osaka 570±8507, Japan

Hmm maybe some confusion. I think the other poster was talking about a direct laryngoscopy/intubation with bougie. After bougie insertion are you leaving blade in for constant visualization and having someone feed ETT. OR are you intubating bougie and moving tube through while taking out blade (having to push tube through some soft tissue that’s not longer lifted)? Whether the tube is pre-loaded or you load it yourself?

 

[Katheudontas parateroumen]

Hmm maybe some confusion. I think the other poster was talking about a direct laryngoscopy/intubation with bougie. After bougie insertion are you leaving blade in for constant visualization and having someone feed ETT. OR are you intubating bougie and moving tube through while taking out blade (having to push tube through some soft tissue that’s not longer lifted)? Whether the tube is pre-loaded or you load it yourself?

Oh I see my bad. To think of it, if I have two people then I’m doing direct visualization as the second person railroads. Only makes sense to do that I think. But when I’m alone I have to do it blindly needing both hands to advance and hold the boogie. What does everyone else do?

 

[jw3600]

Oh I see my bad. To think of it, if I have two people then I’m doing direct visualization as the second person railroads. Only makes sense to do that I think. But when I’m alone I have to do it blindly needing both hands to advance and hold the boogie. What does everyone else do?

I do 2 man (Or 2 woman, or 2 zed 😉. Ya know, 21st century) as the second person really needs no more than 2 brain cells to put tube on, correct orientation preferably, and just let it slide to me. Then I push through cords as I see fit. I have pre loaded bougie with tube before as well but I’m not as smooth during an emergent airway at this point as I’d like to be.

 

[woopedazz]

Are you able to get McGrath batteries now? I ordered one a month ago and its been on back order. Ended up picking up a couple on ebay. I only have one scope. BTW the batteries are proprietary but they can be hacked. Ive been discarding used ones but now I will be saving them just in case

I'm not sure. We're transitioning away from them and now have CMACs. To confirm the other statement made about the batteries: The battery factory is in Wuhan China. I believe we used to get them shipped directly from the distributor in China itself, which is why our supply was suddenly cut (but I'm not 100% on that). We bought as many as we could off SEA/USA eBay and put McGraths in the controlled-substance drug safes to buy time to transition to another VL type. There were a few sad Obstetric Anaesthesia Fellows in the interim.

 

[pgg]

Well guess I must be incompetent then.
Yup that must be it.
Not a reaction to seeing so many people die from premature intubations by inexperienced.
Nope, I must be incompetent.

So you yell at them?

My point is that yelling is what bad teachers do.

I'm sure you're very good at putting tubes in people at the right time.

 

[chocomorsel]

Oh I see my bad. To think of it, if I have two people then I’m doing direct visualization as the second person railroads. Only makes sense to do that I think. But when I’m alone I have to do it blindly needing both hands to advance and hold the boogie. What does everyone else do?

Once you have come out of the mouth to put the ETT on the bougie, you advance it into the mouth and then at that point can’t you can look again with DL and advance the tube and see it’s going in the right hole over the bougie?

 

[chocomorsel]

So you yell at them?

My point is that yelling is what bad teachers do.

I'm sure you're very good at putting tubes in people at the right time.

Yup. Because she panick intubated a patient with sats in the 90s right before they pushed the Etomidate. Yeah. Good thing I am not a teacher and have no desire to be one. Never have claimed to be a good one. Even if I was one no way could I handle these entitled millennials and their cry baby attitudes.
I stay away from academics.
I am just a lowly traveler who goes from one temp job to another. I won’t be there long. I will leave them to tube as they want when I am out.

WTH do I know?
Besides the fact that I will never get the teacher of the year award.

 

[jw3600]

Once you have come out of the mouth to put the ETT on the bougie, you advance it into the mouth and then at that point can’t you can look again with DL and advance the tube and see it’s going in the right hole over the bougie?

Certainly can. But sometimes isn’t the point of the laryngoscope to keep soft tissue out of the way? I have had times where someone with a large tongue/soft palate blocks the tube from sliding in easy over the bougie.

 

[chocomorsel]

Certainly can. But sometimes isn’t the point of the laryngoscope to keep soft tissue out of the way? I have had times where someone with a large tongue/soft palate blocks the tube from sliding in easy over the bougie.

I am so confused. So use the Laryngoscope again after the ETT is over the bougie, inside the mouth, but not deep, to make sure you are going in the correct hole. Maybe I didn’t explain it correctly.

 

[jw3600]

I am so confused. So use the Laryngoscope again after the ETT is over the bougie, inside the mouth, but not deep, to make sure you are going in the correct hole. Maybe I didn’t explain it correctly.

You make sense. Just for emergent airways I don’t know if I can justify doing direct laryngoscopy twice for an intubation. This technique kind of loses its usefulness for me then.

 

[chocomorsel]

You make sense. Just for emergent airways I don’t know if I can justify doing direct laryngoscopy twice for an intubation. This technique kind of loses its usefulness for me then.

It takes like an extra five seconds. Just trying to increase your chances of success if the tube is going in the wrong hole because you are not visualizing it. Which these new plastic lightweight scopes you can just leave them in the mouth actually.

 

[woopedazz]

I agree ETTs should be railroaded over bougies under vision, but I'm a bit confused as to what you're saying @chocomorsel

You're advocating that solo practitioners should insert the laryngoscope, get a view, place the bougie, then remove the laryngoscope, then load the ETT, then insert the laryngoscope, get a view, then railroad the ETT?

Why not do what most people do and preload the bougie with the ETT? Personally, I think it takes away the entire point of using a bougie over a stylet in the first place, but most people do it and I think it's better than losing your view.

OR, my technique:
Insert unloaded and easily manoeuvred bougie as it was designed to be used --> palm off the bougie from your instrumenting hand to your VL hand (still with a view and the bougie still under vision) --> you grasp it in your fingers still wrapped around the VL grip --> now you have the VL and bougie secured and under vision with your VL hand and your other hand completely free --> load and railroad ETT with your free hand. You only need to get one view and the entire thing is done under vision.

 

[chocomorsel]

I agree ETTs should be railroaded over bougies under vision, but I'm a bit confused as to what you're saying @chocomorsel

You're advocating that solo practitioners should insert the laryngoscope, get a view, place the bougie, then remove the laryngoscope, then load the ETT, then insert the laryngoscope, get a view, then railroad the ETT?

Why not do what most people do and preload the bougie with the ETT? Personally, I think it takes away the entire point of using a bougie over a stylet in the first place, but most people do it and I think it's better than losing your view.

OR, my technique:
Insert unloaded and easily manoeuvred bougie as it was designed to be used --> palm off the bougie from your instrumenting hand to your VL hand (still with a view and the bougie still under vision) --> you grasp it in your fingers still wrapped around the VL grip --> now you have the VL and bougie secured and under vision with your VL hand and your other hand completely free --> load and railroad ETT with your free hand. You only need to get one view and the entire thing is done under vision.

Do normal people go in with a plan to use a bougie? I thought one uses a bougie when you run into unanticipated difficulty and can't make the curve/angle or have a good view or something so you go in with the bougie that is stiffer and feel for the rings after the fact? It's a difficult airway device is it not? And then at that point you reach for the ETT place it over bougie and try to get a view again, check to see bougie hasn't moved by feeling for the rings and then railroading the ETT over it.

Anyway, I can't say I have used the bougie in years, because these days we have Glidescopes and Cmacs everywhere. That's the point of this thread isn't it?

 

[woopedazz]

Anyway, I can't say I have used the bougie in years, because these days we have Glidescopes and Cmacs everywhere. That's the point of this thread isn't it?

I still like to have an unopened bougie next to me whenever I use a McGrath in case it's hard to get around the curve

 

[BobLoblaw78]

What if their mouth is small? Glidescope plus DLT is pretty bulky.

Lateral tension release incisions of the oral orifice followed by relocation of semi-permanent dental structures usually improves my view. It takes a couple of times to become proficient. Give it a try

 

[BobLoblaw78]

Yelling is the last refuge of an incompetent teacher, and a sign of someone whose composure has been misplaced. The only time anesthesiologists should ever raise their voices is to be heard in a noisy room.

I have of course learned things from people who've yelled at me. More than they intended to teach, actually. The best thing about some teachers is how they demonstrate what not to do or how not to behave.

I agree and get what you are saying, but I was thinking about this at a girls b-ball game last night. Coach that cares about his players but was yelling at them. I finally thought to my own experiences. Sometimes for us stubborn, hard-headed people it takes yelling to reprioritize our brains thinking order. Like everything in life, it is how you do it and how it is delivered. You can repeatedly try to politely tell your 10 yo to look both ways before crossing the road or you can give an exaggerated response that sticks in their brain. It would suck to make a mistake in certain situations b/c you don't get a second chance to learn (or the patient doesn't get a second chance). I can't stand the coaches/teachers that you can tell suck the will and life out of teams.

Side note- I would tell my kids that they were dead when they wouldn't look crossing the road and couldn't talk for 5-10 minutes (not quite the full death experience but it was funny to see some of the looks I got from others)

 

[GassYous]

I still like to have an unopened bougie next to me whenever I use a McGrath in case it's hard to get around the curve

I don't even stylet the tube with the mcgrath because I know my way around curves.

 

[woopedazz]

I don't even stylet the tube with the mcgrath because I know my way around curves.

Yeah, i never stylet. But i do find myself reaching for the bougie to help me through a little too often for my liking. A lot of tiny south east asian airways where I work. I definitely need to improve on my ability to get the tube anterior enough without an adjunct.

 

[mdawarre]

Once you have come out of the mouth to put the ETT on the bougie, you advance it into the mouth and then at that point can’t you can look again with DL and advance the tube and see it’s going in the right hole over the bougie?

you could DL twice but why bother taking the blade out of the mouth?

 

[mdawarre]

Do normal people go in with a plan to use a bougie? I thought one uses a bougie when you run into unanticipated difficulty and can't make the curve/angle or have a good view or something so you go in with the bougie that is stiffer and feel for the rings after the fact? It's a difficult airway device is it not? And then at that point you reach for the ETT place it over bougie and try to get a view again, check to see bougie hasn't moved by feeling for the rings and then railroading the ETT over it.

Anyway, I can't say I have used the bougie in years, because these days we have Glidescopes and Cmacs everywhere. That's the point of this thread isn't it?

Maybe it's me-I have trouble sometimes feeling the rings on female pts. and I don't like doing anything blind. I almost never use the bougie because of VL availability for the past several years. I find bougies floppy, especially when you're using them with VL rather than DL, because they need to travel so anteriorly and you're not getting the tissue displacement that you get with DL.

 

[mdawarre]

Yeah, i never stylet. But i do find myself reaching for the bougie to help me through a little too often for my liking. A lot of tiny south east asian airways where I work. I definitely need to improve on my ability to get the tube anterior enough without an adjunct.

You are probably already doing this but withdraw the scope a tad and the laryngeal inlet drops down (less anterior). It's counterintuitive.

 

[mdawarre]

I agree ETTs should be railroaded over bougies under vision, but I'm a bit confused as to what you're saying @chocomorsel

You're advocating that solo practitioners should insert the laryngoscope, get a view, place the bougie, then remove the laryngoscope, then load the ETT, then insert the laryngoscope, get a view, then railroad the ETT?

Why not do what most people do and preload the bougie with the ETT? Personally, I think it takes away the entire point of using a bougie over a stylet in the first place, but most people do it and I think it's better than losing your view.

OR, my technique:
Insert unloaded and easily manoeuvred bougie as it was designed to be used --> palm off the bougie from your instrumenting hand to your VL hand (still with a view and the bougie still under vision) --> you grasp it in your fingers still wrapped around the VL grip --> now you have the VL and bougie secured and under vision with your VL hand and your other hand completely free --> load and railroad ETT with your free hand. You only need to get one view and the entire thing is done under vision.

Do you find that the bougie advances as you are railroading the ett, when you do these by yourself? That is my worry. You don't always have time to lube it.

 

[pjl]

Side note- I would tell my kids that they were dead when they wouldn't look crossing the road and couldn't talk for 5-10 minutes (not quite the full death experience but it was funny to see some of the looks I got from others)

Well, that is an interesting parenting technique.

I suspect my wife would tell me I was dead if I did that, and she wouldn’t engage in “relations” for 5-10 days if I did that.