Glidescope vs DL

[TheComebacKid]

VL 100%. All the way.

I'm pretty fresh out of residency. I trained with C-MAC, the standard "attending turns the screen away so you can DL" model. I feel like in the ~150 intubations I did in residency, my DL skills weren't bad. I started using the Glidescope as an attending with a hyperangulated blade and rigid stylet, and overall prefer the CMAC and is still my go to when I work solo or with residents.

As others have stated, VL has higher first pass success rates. I don't buy this whole thing about how "you have to know DL just in case". If you know how to use suction and SALAD technique, VL is pretty much all you need.

I work in EMS and we have seen an unbelievable increase in our overall first pass success rates since switching to VL. I know there are studies that don't show much difference between the two techniques, but internally on all of my reviews the difference between VL and DL is staggering and favors VL.

For trainees also, I think being able to record a video of their intubation and review it them afterwards and discuss certain points is very worthwhile and better for teaching purposes.

The biggest downside to using VL is that often times trainees become lackadaisical with important things like proper positioning, or heaven forbid, preoxygenation since they are so used to how quickly and fast they can intubate on VL. These factors are still critical in my opinion even when using VL.

I am not sure why people are so dogmatic about using other harder methods to accomplish the same task. It's OKAY that VL is easier. This whole "back in my day..." approach is crazy talk. Also, I don't buy it when people say "I think DL is easier than VL". As someone who trained extensively with both, there is no question for me that VL is easier. I suspect that those folks using DL are just in a comfortable state and don't feel the need to learn another technique. There is a learning curve to VL, but I think people can become more proficient at it much faster than you can with DL.

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[Jabbed]

VL 100%. All the way.

I'm pretty fresh out of residency. I trained with C-MAC, the standard "attending turns the screen away so you can DL" model. I feel like in the ~150 intubations I did in residency, my DL skills weren't bad. I started using the Glidescope as an attending with a hyperangulated blade and rigid stylet, and overall prefer the CMAC and is still my go to when I work solo or with residents.

Ironically, saying that you're more comfortable with CMAC because that's what you trained on is analogous to the dinosaurs saying that they're more comfortable with DL because that's what they trained on.

As others have stated, VL has higher first pass success rates. I don't buy this whole thing about how "you have to know DL just in case". If you know how to use suction and SALAD technique, VL is pretty much all you need.

I work in EMS and we have seen an unbelievable increase in our overall first pass success rates since switching to VL. I know there are studies that don't show much difference between the two techniques, but internally on all of my reviews the difference between VL and DL is staggering and favors VL.

I initially started with VL hyperangulated and DL with Mac/Miller. I would say that my learning curve for VL was ~10 intubations before I felt comfortable and about ~100 intubations for DL. For the average medic who maybe intubates successfully 1-2 times a year (maybe your area is different than mine), I would agree that VL-focused training and protocols make more sense. As an aside are they using preloaded tubes like the McGrath?

With regards to VL and SALAD-- it's a great paradigm that's definitely improved the scope and success of VL, but all that is doing is optimizing your first pass success. If your first pass fails, your mostly widely available backup will still be DL. Cases that required non-VL, non-surgical airways that I've had over the past year: floor code 2/2 vomit/aspiration with broken wall suction that required digital intubation, kid shot through the mandible bleeding from the tongue (blood kept falling into the airway rather than rising from posterior oropharynx), and a vomit-aspiration while transporting to cath lab elevator code with an airway box that didn't have VL or suction.

The biggest downside to using VL is that often times trainees become lackadaisical with important things like proper positioning, or heaven forbid, preoxygenation since they are so used to how quickly and fast they can intubate on VL. These factors are still critical in my opinion even when using VL.

From a training perspective, I think that this is the real issue. The fact that you don't have to do it in the majority of cases means that you won't end up doing it at all, and that your trainees won't even think about it when shtf. Things that I see people neglect with VL often: good sniffing position, good scissoring technique, engaging the hyoepiglottic ligament correctly, external laryngeal manipulation, and using adjuncts like Frovas when indicated.

At the end of the day though, I personally believe that we as a specialty need to be airway experts. Working with a half-empty toolkit and not being comfortable with arguably the most widely available airway instrument is anathema to this.

 

[skougess]

At the end of the day though, I personally believe that we as a specialty need to be airway experts. Working with a half-empty toolkit and not being comfortable with arguably the most widely available airway instrument is anathema to this.

There's not being comfortable with DL (which I think no one is arguing for) and then there's stick-in-the-mud-dinosaur "I DL 99% of the time" perspective. The latter is just as dangerous and outdated as doing central lines without ultrasound 99% of the time. In an OR setting with optimized patients, starting with a DL most of the time is fine. But I would argue that easily half of my intubations in the ED are tenuous and really should be done VL to optimize first pass success. If it was my mom on the stretcher with a best pre-ox sat of 88%, I wouldn't want the doctor starting with DL because their ego can't handle the alternative.

 

[Jabbed]

There's not being comfortable with DL (which I think no one is arguing for) and then there's stick-in-the-mud-dinosaur "I DL 99% of the time" perspective. The latter is just as dangerous and outdated as doing central lines without ultrasound 99% of the time. In an OR setting with optimized patients, starting with a DL most of the time is fine. But I would argue that easily half of my intubations in the ED are tenuous and really should be done VL to optimize first pass success. If it was my mom on the stretcher with a best pre-ox sat of 88%, I wouldn't want the doctor starting with DL because their ego can't handle the alternative.

The original topic was whether or not trainees should be forced to practice DL in order to build proficiency. You can't build proficiency without repetition.

Again, first pass success and time to intubation between DL and VL for experienced practitioners is similar in all the larger RCTs and meta-analyses.

 

[skougess]

The original topic was whether or not trainees should be forced to practice DL in order to build proficiency. You can't build proficiency without repetition.

Again, first pass success and time to intubation between DL and VL for experienced practitioners is similar in all the larger RCTs and meta-analyses.

You say this, but actually looking at the body of literature states the opposite (I realize there are some studies that show them equivocal). VL is clearly superior to DL.

Even anecdotally speaking it makes sense. Look at everyone on this thread talking about "turning the camera away." That's because the view on VL is generally gorgeous QUICKLY, even if you can nearly always eventually get a decent view with DL.

 

[Jabbed]

You say this, but actually looking at the body of literature states the opposite (I realize there are some studies that show them equivocal). VL is clearly superior to DL.

Even anecdotally speaking it makes sense. Look at everyone on this thread talking about "turning the camera away." That's because the view on VL is generally gorgeous QUICKLY, even if you can nearly always eventually get a decent view with DL.

There's a Cochrane review from 2016 with no evidence to support the idea that VL reduces the number of intubation attempts, time to intubation, or procedural complications.

And you're right, the VL view is generally gorgeous quickly in 90% of cases; which means that trainees have no impetus to routinely practice other useful airway skills until they're attempting the 1-10% of difficult airways.

 

[skougess]

There's a Cochrane review from 2016 with no evidence to support the idea that VL reduces the number of intubation attempts, time to intubation, or procedural complications.

And you're right, the VL view is generally gorgeous quickly in 90% of cases; which means that trainees have no impetus to routinely practice other useful airway skills until they're attempting the 1-10% of difficult airways.

Again, no one is arguing that EM residents should come out of residency uncomfortable with DL. It is an essential skill.

Guess we’re gonna have to agree to disagree on this one. I know if my family member ever needs to be tubed emergently, I’m gonna ask that they please use the VL up front. I’m betting deep down you would too.

 

[turkeyjerky]

Again, no one is arguing that EM residents should come out of residency uncomfortable with DL. It is an essential skill.

Guess we’re gonna have to agree to disagree on this one. I know if my family member ever needs to be tubed, I’m gonna ask that they please use the VL up front. I’m betting deep down you would too.

I don't really see how one could say that all patients should be intubated with VL but also that DL is an essential skill that should be mastered by trainees.

I feel a little bit bad for the current crop of residents. I don't think they'll be provided the same opportunity to master airway management that those of us who came out a little bit ago did.

 

[alpinism]

The problem is that most residents barely get 50-100 ED tubes nowadays which is not enough to master both techniques.

Since most places are doing 90% VL that means many residents are only getting 10% DL tubes before graduation.

The fact is that residents actually need more DL and less VL tubes if we truly believe that its an essential skill.

 

[skougess]

I don't really see how one could say that all patients should be intubated with VL but also that DL is an essential skill that should be mastered by trainees.

I feel a little bit bad for the current crop of residents. I don't think they'll be provided the same opportunity to master airway management that those of us who came out a little bit ago did.

“I don’t see how you can say we should use ultrasound for central lines, but mastering a blind fem should be part of training. “

This is how this argument sounds to me tbh. And again, for I think the fourth time? I am not saying all patients should be intubated with a VL. But 95% of them in the ED should at least start that way.

 

[gamerEMdoc]

It all comes down to what you first learned on.

IDK, I first learned on DL and if I am tubing someone tomorrow, I'm grabbing the CMAC if available. I just like the better view personally. Doesn't mean I can't DL if CMAC isn't available, I can, but its still my preference.

 

[Mount Asclepius]

Interesting thread with many great points. I think DL is an important skill to have mastered in the airway toolbox. Now days, I usually use VL as it's easier and helps keep my video game skills sharp, but with predicted easy airways that are primarily for airway protection in young people I usually use DL in order to maintain competency. In a busy ED I only intubate 1-2 times per month and think practicing a different method when feasible is worthwhile. Whether it's DL or VL, I think plastic in the trachea is overrated though. HFNC and BiPAP win hands down.

 

[GeneralVeers]

Absolutely should learn on DL and then move to VL. I can't count the times the Glidescope equipment hasn't been ready.....no blade, or no rigid stylet and had to just go with DL.

 

[Apollyon]

Absolutely should learn on DL and then move to VL. I can't count the times the Glidescope equipment hasn't been ready.....no blade, or no rigid stylet and had to just go with DL.

But, but, but - you're a dinosaur!

 

[GeneralVeers]

But, but, but - you're a dinosaur!

I'm comfortable with both. I just use whatever isn't going to take me 10 minutes to get set up and find parts.

 

[Angry Birds]

I'm comfortable with both. I just use whatever isn't going to take me 10 minutes to get set up and find parts.

Another plug for my go-to device: I carry the King Vision VL in my own bag. This way I don't rely on anyone and am ready to go at all times. I even include in my airway bag an ET tube, nasal trumpets, bougie, scalpel, etc.
But, seriously, the best device ever is the King Vision VL.

 

[GassYous]

Another plug for my go-to device: I carry the King Vision VL in my own bag. This way I don't rely on anyone and am ready to go at all times. I even include in my airway bag an ET tube, nasal trumpets, bougie, scalpel, etc.
But, seriously, the best device ever is the King Vision VL.

Ha I used to have a go bag like that for residency. Too many idiots put too much useless crap in the communal bag and didn't replace the stuff that we actually use.

 

[Groove]

I’ve got a Mcgrath in my car actually that I take with me when I have to work a shift in an ED where I’m responsible for responding to floor codes. Love that little thing. I wish the batteries weren’t proprietary though.

 

[bravotwozero]

I’ve got a Mcgrath in my car actually that I take with me when I have to work a shift in an ED where I’m responsible for responding to floor codes. Love that little thing. I wish the batteries weren’t proprietary though.

Is that the one with the camera and video screen built right into laryngoscope? Those are bad@ss.

 

[GassYous]

Is that the one with the camera and video screen built right into laryngoscope? Those are bad@ss.

Yes it is perfect. Small blade size, fits in almost any mouth. Clear camera. Very light and portable. I don't even bend or stylet the tube.

 

[Angry Birds]

Yes it is perfect. Small blade size, fits in almost any mouth. Clear camera. Very light and portable. I don't even bend or stylet the tube.

WIth King Vision VL, I don't even need/use a stylet.

 

[Siggy]

Though I will say VL is preferred during an arrest if there are active compressions going on.

I probably get about 3/4ths of my codes intubated without holding compressions using DL. The other 1/4th I hold for about a second because I already have the blade in the mouth when I ask compressions to be held. In those instances, there's just a little too much movement to get the tube in. The second the tube is in, though, compressions are restarted.

I haven't tried intubating a code with VL, but I feel that it would be harder to intubate without stopping compressions.

 

[skougess]

I probably get about 3/4ths of my codes intubated without holding compressions using DL. The other 1/4th I hold for about a second because I already have the blade in the mouth when I ask compressions to be held. In those instances, there's just a little too much movement to get the tube in. The second the tube is in, though, compressions are restarted.

I haven't tried intubating a code with VL, but I feel that it would be harder to intubate without stopping compressions.

That’s really bad tbh. You are providing substandard care by not using VL on these patients.

 

[WildEMDoc]

That’s really bad tbh. You are providing substandard care by not using VL on these patients.

Intubating during compressions with a VL IMO makes everything substantially more difficult. The chest compressions motion make the camera view so awful.

I have never not been able to intubate during compressions over a bougie with minimal or no view using DL just to move the tongue. That being said if I was in that situation I wouldn't try a VL, I'd just place an LMA and see if ROSC is obtained or not.

 

[skougess]

Intubating during compressions with a VL IMO makes everything substantially more difficult. The chest compressions motion make the camera view so awful.

I have never not been able to intubate during compressions over a bougie with minimal or no view using DL just to move the tongue. That being said if I was in that situation I wouldn't try a VL, I'd just place an LMA and see if ROSC is obtained or not.

My shop almost exclusively uses VL to tube during codes, and I can't remember the last time someone had to stop compressions to get the tube.

 

[Siggy]

That’s really bad tbh. You are providing substandard care by not using VL on these patients.

Please provide evidence supporting that VL is the standard of care for cardiac arrest intubations.

My shop almost exclusively uses VL to tube during codes, and I can't remember the last time someone had to stop compressions to get the tube.

Just because "your shop" (you've listed yourself a a medical student, is it really "your shop"?) does something someway doesn't make it the standard of care.

By the way, I can't remember the last time I've seen the ED at my hospital -not- stop compressions for a tube when I've wandered down there to get a head start (if ROSC occurs) when one is called.

 

[skougess]

Please provide evidence supporting that VL is the standard of care for cardiac arrest intubations.



Just because "your shop" (you've listed yourself a a medical student, is it really "your shop"?) does something someway doesn't make it the standard of care.

By the way, I can't remember the last time I've seen the ED at my hospital -not- stop compressions for a tube when I've wandered down there to get a head start (if ROSC occurs) when one is called.

The evidence is that you’re having to stop compressions 25% of the time to get the tube…that is unacceptable.

Im not a medical student.

 

[Siggy]

The evidence is that you’re having to stop compressions 25% of the time to get the tube…that is unacceptable.

Im not a medical student.

...then you should update your profile.

Stopping compressions for 2 seconds on occasion isn't a problem. Doing the entire intubation with stopped compressions, however is. Again, I can't remember the last time I didn't see the ED at my hospitals -not- stop compressions.

 

[Groove]

I probably get about 3/4ths of my codes intubated without holding compressions using DL. The other 1/4th I hold for about a second because I already have the blade in the mouth when I ask compressions to be held. In those instances, there's just a little too much movement to get the tube in. The second the tube is in, though, compressions are restarted.

I haven't tried intubating a code with VL, but I feel that it would be harder to intubate without stopping compressions.

I used to do this exclusively and (assuming I don't have VL readily accessible) as long as they are able to bag with good chest rise, I typically will wait for one of the pulse checks to tube with DL. That being said, It's hard not to have that occasional tube where they are ready to re-start compressions and I'm going "Wait a sec..." to give me a split second longer to get the tube in. I find it hard to believe that anyone doing DL in a code doesn't have a similar pause for intubation with regularity. VL typically allows me to get the tube in without any pause in compressions.

As far as floor codes, the Mcgrath, or any of these battery powered ultra portable VL devices are super easy to grab and run to a code. If it's not a code, I typically revert to 100% DL or 95% at the very least unless I anticipate a difficult airway. Luckily, I only have to respond to codes in our outlying community EDs. At our main hospital, the ICU responds.

 

[skougess]

View attachment 339729
...then you should update your profile.

Stopping compressions for 2 seconds on occasion isn't a problem. Doing the entire intubation with stopped compressions, however is. Again, I can't remember the last time I didn't see the ED at my hospitals -not- stop compressions.

Nah, I’d rather keep it and make people look foolish when they attempt ad-hominem arguments.

 

[Fox800]

Nah, I’d rather keep it and make people look foolish when they attempt ad-hominem arguments.

Show me on the doll where DL touched you.

I DL frequently, including during codes. I don't stop compressions to intubate, ever.

Mac 4 + ELM + bougie. Just like how the really clinically strong physician-led prehospital services do it (London's Air Ambulance, Sydney HEMS). Set up to do it the same way, every time.

I have a Glidescope on and ready as a backup. If you've ever tried to use a Glidescope in an airway that's covered in thick cobweb-like secretions, vomit, or blood, you know how quickly that goes sideways when your camera is obscured and the tech/RT knocks your suction off the bed.

It's not "really bad" to DL during a cardiac arrest. Show me data that attending physicians using DL vs VL have objectively worse outcomes (lower incidences of ROSC, increased mortality rates or HIE, increased use of rescue devices or cricothyroidotomies). I bet you can't.

 

[AlmostAnMD]

Not sure where all this "gotta use DL during codes" comes from

I insert VL blade during CPR and effortlessly place tube if there isn't tube in place. "camera moves too much" sounds like made up nonsense or people just aren't comfortable with VL. Like Tenk said if you grew up playing video games it's just so natural to use.

If they arrive with an igel I leave in in place and only swap it out if there is ROSC. I have a dot phrase I use that cites literature that reports it being unnecessary to swap out a functioning igel if no ROSC happens. Main reason for that is simply laziness and no desire to formally intubate someone that's been dead for 20+ minutes already tbh

 

[Fox800]

Not sure where all this "gotta use DL during codes" comes from

I insert VL blade during CPR and effortlessly place tube if there isn't tube in place. "camera moves too much" sounds like made up nonsense or people just aren't comfortable with VL. Like Tenk said if you grew up playing video games it's just so natural to use.

If they arrive with an igel I leave in in place and only swap it out if there is ROSC. I have a dot phrase I use that cites literature that reports it being unnecessary to swap out a functioning igel if no ROSC happens. Main reason for that is simply laziness and no desire to formally intubate someone that's been dead for 20+ minutes already tbh

Perfect person to practice your DL on. No one cares what their sats are pre-intubation if they are in cardiac arrest. You can take your time.

 

[GeneralVeers]

Not sure where all this "gotta use DL during codes" comes from

I insert VL blade during CPR and effortlessly place tube if there isn't tube in place. "camera moves too much" sounds like made up nonsense or people just aren't comfortable with VL. Like Tenk said if you grew up playing video games it's just so natural to use.

If they arrive with an igel I leave in in place and only swap it out if there is ROSC. I have a dot phrase I use that cites literature that reports it being unnecessary to swap out a functioning igel if no ROSC happens. Main reason for that is simply laziness and no desire to formally intubate someone that's been dead for 20+ minutes already tbh

Agree completely. I don't swap out the temporary airway devices unless there is ROSC. Also I don't intubate patients who've been down for 40 minutes or longer, cuz if they've been that long without an airway they are dead, dead, dead.

 

[Groove]

There's not being comfortable with DL (which I think no one is arguing for) and then there's stick-in-the-mud-dinosaur "I DL 99% of the time" perspective. The latter is just as dangerous and outdated as doing central lines without ultrasound 99% of the time. In an OR setting with optimized patients, starting with a DL most of the time is fine. But I would argue that easily half of my intubations in the ED are tenuous and really should be done VL to optimize first pass success. If it was my mom on the stretcher with a best pre-ox sat of 88%, I wouldn't want the doctor starting with DL because their ego can't handle the alternative.

Don't let your DL skills atrophy. Aren't you a resident or newly graduated? Over time, you absolutely will find yourself in a situation where the glidescope or VL is NOT available. That might be a floor code, an ICU code, an ED code where the only glidescope is being used on another patient who is also coding at the same time, code in the CT scanner or MRI, pedi code where nobody can find the pedi blades, regular code where there's a missing part or the screen shorts out. I've seen it all. Also, don't underestimate someone's abilities who is proficient with DL.

Always push yourself throughout your career to master techniques that you are uncomfortable with...it will pay off. Even your comment about any line without US as being outdated. What are you gonna do when you race to that floor code in your tiny outlying hospital that you recently got credentialed in and got called by your ED director to cover the night shift because one of the "old dinosaur" docs had a heart attack (Probably @Birdstrike if he had been forced to continue practicing EM )? It's 2a.m. and you've got no glidescope and no ultrasound and lying in front of you is a hypotensive respiratory arrest who needs intubation and a CVL. Old dinosaur would intubate with DL and pop in a subclavian CVL, resuscitate, move them to the 4 bed ICU, call the intensivist who doesn't staff the ICU at night and hopefully is going to drive in to manage the pt, walk back down to the ED, finish the shift and call it a night. What about you? I'm saying all of this partially in jest, but seriously...there's absolutely a place for traditional techniques. These hypothetical scenarios most definitely occur, even if it's infrequently.

Ironically, it's the classical techniques that tend to bail me out of the occasional crisis scenario.

 

[NicMouse64]

Don't let your DL skills atrophy. Aren't you a resident or newly graduated? Over time, you absolutely will find yourself in a situation where the glidescope or VL is NOT available. That might be a floor code, an ICU code, an ED code where the only glidescope is being used on another patient who is also coding at the same time, code in the CT scanner or MRI, pedi code where nobody can find the pedi blades, regular code where there's a missing part or the screen shorts out. I've seen it all. Also, don't underestimate someone's abilities who is proficient with DL.

Always push yourself throughout your career to master techniques that you are uncomfortable with...it will pay off. Even your comment about any line without US as being outdated. What are you gonna do when you race to that floor code in your tiny outlying hospital that you recently got credentialed in and got called by your ED director to cover the night shift because one of the "old dinosaur" docs had a heart attack (Probably @Birdstrike if he had been forced to continue practicing EM )? It's 2a.m. and you've got no glidescope and no ultrasound and lying in front of you is a hypotensive respiratory arrest who needs intubation and a CVL. Old dinosaur would intubate with DL and pop in a subclavian CVL, resuscitate, move them to the 4 bed ICU, call the intensivist who doesn't staff the ICU at night and hopefully is going to drive in to manage the pt, walk back down to the ED, finish the shift and call it a night. What about you? I'm saying all of this partially in jest, but seriously...there's absolutely a place for traditional techniques. These hypothetical scenarios most definitely occur, even if it's infrequently.

Ironically, it's the classical techniques that tend to bail me out of the occasional crisis scenario.

I did a CVL traditional technique while the attending had an ultrasound probe on the patient and screen turned away from me. There's absolutely ways to teach traditional techniques without increasing the chance of harm to a patient......

 

[turkeyjerky]

I did a CVL traditional technique while the attending had an ultrasound probe on the patient and screen turned away from me. There's absolutely ways to teach traditional techniques without increasing the chance of harm to a patient......

That sound unnecessarily weird and awkward to me. In that instance, I doubt you were really doing either technique (US or landmark based) in the best manner. Plus part of the skill in doing an US guided line is holding the probe yourself and keeping view of the needle. This sounds like it was some BS attempt by your attending to satisfy a departmental mandate that all lines be US guided.

A big part of these 'outdated' techniques, is learning how to troubleshoot and adjust when the first attempt is unsuccessful. Having a crutch available makes it exponentially less likely that you'll be able to do so. It's why my LP abilities when through the roof after I finished residency.

 

[NicMouse64]

That sound unnecessarily weird and awkward to me. In that instance, I doubt you were really doing either technique (US or landmark based) in the best manner. Plus part of the skill in doing an US guided line is holding the probe yourself and keeping view of the needle. This sounds like it was some BS attempt by your attending to satisfy a departmental mandate that all lines be US guided.

A big part of these 'outdated' techniques, is learning how to troubleshoot and adjust when the first attempt is unsuccessful. Having a crutch available makes it exponentially less likely that you'll be able to do so. It's why my LP abilities when through the roof after I finished residency.

Wasn't awkward at all. This was on an anesthesia rotation in the cardiac room and he's been teaching med students this way for years. Bolded part probably is true. I think there's some evidence out there that US-guided has lower rates of complications. At any rate, I appreciate that the attending was willing to give medical students an education rather than have us sit on the sidelines.......

 

[sylvanthus]

lll prob get shat on, but in ICU im pure glidescope. I always have RT on hand with glidescope on all intubations. I dont have to worry about proper patient positioning, and can generally toss it in faster because of this. I also have a lma and DL on hand if I need it. So far, it hasnt been a problem in 2 years.

 

[Birdstrike]

... called by your ED director to cover the night shift because one of the "old dinosaur" docs had a heart attack (Probably @Birdstrike if he had been forced to continue practicing EM )? It's 2a.m. and you've got no glidescope and ...

I'm 48 which makes me 72 in EM years, so yes, I'm quite dinosaurish in EM circles. I "identify" as a 20 year old, though. So, from time to time I'll do things like run 12 miles and drop a sub 6 minute mile in the middle of it, so I don't feel so paleantologic.

 

[GeneralVeers]

No one "needs" a CVL. They are nice to have, and convenient for ICU. If no US available I wouldn't waste my time. There are multiple other ways to get IV access, and pressors can be run overnight through a peripheral.

 

[Groove]

No one "needs" a CVL. They are nice to have, and convenient for ICU. If no US available I wouldn't waste my time. There are multiple other ways to get IV access, and pressors can be run overnight through a peripheral.

Oh c'mon Veers, you know that's not always true. We just SAY that when we don't feel like placing a CVL.

 

[Angry Birds]

I'm 48 which makes me 72 in EM years, so yes, I'm quite dinosaurish in EM circles. I "identify" as a 20 year old, though. So, from time to time I'll do things like run 12 miles and drop a sub 6 minute mile in the middle of it, so I don't feel so paleantologic.

View attachment 339790

Crazy how time flies and life moves on.
I also feel 25.

 

[Birdstrike]

Crazy how time flies and life moves on.
I also feel 25.

It is crazy. I've had several elderly patients tell me, "The older you get, the faster it goes!" Lol. Not sure if that's a good thing or a bad thing.

 

[Angry Birds]

It is crazy. I've had several elderly patients tell me, "The older you get, the faster it goes!" Lol. Not sure if that's a good thing or a bad thing.

Do you ever get sad over it? I do. I have a hard time thinking about my age and feel like having a mid-life crisis or something. I feel like medicine takes away the best decade or so of our lives.

 

[Birdstrike]

Do you ever get sad over it? I do.

If I said 'never,' I'd be lying. But I trying to embrace my old-dudeness, now.

About 15 years ago, my wife and I ran a 5K race. We were in reasonably good shape, but not super fit. We didn't train or work at it, because we were young. I remember being passed by this really old looking dude going the other way, way ahead of me. He had crazy old-dude hair, a 1970's headband, 1980's Magnum P.I. short shorts and white socks pulled up to almost his knees; you know, the super high ones with the two green stripes at the top. He just looked outrageous, but was moving real fast and obviously trained hard to be as fit as he was, beating 99% of people decades younger than him.

He absolutely kicked the crap out of me in that race. Lol. I didn't care at the time, but obviously I did enough to remember it 15 years later. He looked so happy and content knowing he beat the pants off of everyone else in that race (except 1 or two people, maybe). I'm that old guy now. And lovin' it.

My point: Embrace the best of where you're at right now, because even though you're older than you've been, you're much younger that you're going to be. Don't be jealous of your past self. Enjoy the fact that your future self is jealous of you, as you are, now.

Oh. And, glidescopes, too. Yeah. Glidescopes.

 

[Angry Birds]

If I said 'never,' I'd be lying. But I trying to embrace my old-dudeness, now.

About 15 years ago, my wife and I ran a 5K race. We were in reasonably good shape, but not super fit. We didn't train or work at it, because we were young. I remember being passed by this really old looking dude going the other way, way ahead of me. He had crazy old-dude hair, a 1970's headband, 1980's Magnum P.I. short shorts and white socks pulled up to almost his knees; you know, the super high ones with the two green stripes at the top. He just looked outrageous, but was moving real fast and obviously trained hard to be as fit as he was, beating 99% of people decades younger than him.

He absolutely kicked the crap out of me in that race. Lol. I didn't care at the time, but obviously I did enough to remember it 15 years later. He looked so happy and content knowing he beat the pants off of everyone else in that race (except 1 or two people, maybe). I'm that old guy now. And lovin' it.

My point: Embrace the best of where you're at right now, because even though you're older than you've been, you're much younger that you're going to be. Don't be jealous of your past self. Enjoy the fact that your future self is jealous of you, as you are, now.

Oh. And, glidescopes, too. Yeah. Glidescopes.

Very true. Especially the bolded part.

 

[emergentmd]

Old Dino here who was taught to do CVL and DL including DPLs during training. Time has changed and change is hard especially when you are not in a trauma center with alot of exposure.

When U/S CVLs were taking hold about 7 Yrs ago at my shop, I knew that was the way to go but when you are doing 1 CLV a month, you will never get good at doing U/S. Yeah I could take a course, but still do not think doing 1/month will get me proficient. I had similar Dinos trying to learn on their occasional CLVs and taking 30-60 min getting one when I could throw one in @ 10 min. I wish I could have learned to do CVLs via U/S but wasn't practical for a dino like me. I will say in my 20+ yr career, I have had ZERO CVL complications and can not think of one pt where I could not get one in. I had an attending spend over 1 hr and multiple sticks to get an IJ give up and ask me to help. Took me 10 min to throw in a SC line.

Same thing for me with VL vs DL about 7 yrs ago. Many of my partners wanted to learn VL so did almost every pt VL to get better. I tried to do VL first but most of the time it took a long time to find the equipment/turn on machine and the thing fogged up so much. I am sure the equipment are much better now and most EDs are quick to set up. But man, was that painful. I could do DL in 30 secs and move on. I told myself I would do VL once the ED gets good at quick setup. Well fast forward 7 yrs, and I just do DL if I ever need it and go VL if I have issues which is rare. I have never broken a tooth either.

Now that I have not been in an ED in 2 yrs, there is no point of learning to do U/S CVLs or start with VL. I have done 2 CVL and 1 DL in the past 2 yrs which is less than some shifts where I did 3 DL and 2 CL in less than 1 hr.