having a very difficult time intubating!

[heathermed]

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first off, I want to apologize for asking something so inherent to what anesthesiologists need to be good at, but I figure it's better to get as much help as I can.

I am currently doing my anesthesiology rotation in Florida and having a very difficult time intubating. My attendings have been very patient with me, but i just can't seem to get it. I was hoping someone could give me another perspective of what I'm doing wrong.

From what I can gather, I believe my main issue is that I'm having difficulty visualizing the vocal cords correctly. I place the blade in deep, come back till the epiglottis flops down, and advance slightly and lift! But I just can't seem to adequately get the epiglottis out of the way. I'm using the curved Mac blade.

I'm sorry if my description is somewhat vague. I'm just very frustrated since I really want to go into anesthesia next year.

any help in terms of how to efficiently
1)find the epiglottis
2)getting it out of the way
3)any words of wisdom

would be greatly appreciated.

thank you very much for taking the time to help,
Heather

 

[sevoflurane]

first off, I want to apologize for asking something so inherent to what anesthesiologists need to be good at, but I figure it's better to get as much help as I can.

I am currently doing my anesthesiology rotation in Florida and having a very difficult time intubating. My attendings have been very patient with me, but i just can't seem to get it. I was hoping someone could give me another perspective of what I'm doing wrong.

From what I can gather, I believe my main issue is that I'm having difficulty visualizing the vocal cords correctly. I place the blade in deep, come back till the epiglottis flops down, and advance slightly and lift! But I just can't seem to adequately get the epiglottis out of the way. I'm using the curved Mac blade.

I'm sorry if my description is somewhat vague. I'm just very frustrated since I really want to go into anesthesia next year.

any help in terms of how to efficiently
1)find the epiglottis
2)getting it out of the way
3)any words of wisdom

would be greatly appreciated.

thank you very much for taking the time to help,
Heather

Hey there HeatherMed. Thanks for posting. 2 quick thoughts:

It's all good. It takes something like 200 intubations to become proficient with airways. So no big deal if you are having trouble. There is a learning curve. Soon you will be a master.

I'm sure many more tips will come out of your post. I'll leave you with one of the most basic yet most important tips to using a MAC blade:
Make sure that you control/sweep the tongue. Come in from the right side of the mouth and scoop that sucker out of the way. Don't just pick it up and let it flop over both sides of the mac blade. Control the tongue and omit it's presence from your view.

Good luck. 🙂

 

[Licoricestick]

Hey there HeatherMed. Thanks for posting. 2 quick thoughts:

It’s all good. It takes something like 200 intubations to become proficient with airways. So no big deal if you are having trouble. There is a learning curve. Soon you will be a master.

I’m sure many more tips will come out of your post. I’ll leave you with one of the most basic yet most important tips to using a MAC blade:
Make sure that you control/sweep the tongue. Come in from the right side of the mouth and scoop that sucker out of the way. Don’t just pick it up and let it flop over both sides of the mac blade. Control the tongue and omit it’s presence from your view.

Good luck. 🙂

I'll second that!
And add, that if you're only doing a month of anaesthesia, the best skill you can learn is face mask ventilation. If you can ventilate, you can push to have a second attempt at intubation, or wait for someone to get there and bail you out.😳

 

[seamonkey]

I'm just finishing up my CA-1 year, and intubation skills are always going to be a work in progress, trust me. The above recs are all good. Occasionally, I just stick the MAC blade in deep, then pull back. Often see I have a Miller-esque view (blade holding up the epigloittis), back off a bit more till it flops down, then advance. Voila! Grade 1 view. As long as you direct your force up and away, you'll get it. Don't be afraid to ask for cricoid pressure to help, ever. Whatever gets the intubation = successful intubation

 

[chocomorsel]

Positioning is a big key. I've had one of my attendings tell me to take the extra pillows away as the head is too flexed and there will be difficulty with extending the head. I used to listen to him, but now I'm like "nah, I'm good" as I think the correct sniffing position helps me out more than extending the neck back and having to use more muscle to lift up the whole head off the pillow to see the cords. Just my opinion.

 

[docdaname]

im glad this subject came up, because I was thinking about starting this thread. Im finishing up my month (and technically starting my CA1 year on thursday), and I suck. First I have trouble getting the freakin thing in the mouth to being with (although ive gotten much better at this part). I struggle with the tongue. And then assuming i get past these two points, 1 of 2 things occurs. Either I see nothing, or i guess a better explanation is, i just see a bunch of pink. Or i see a recognizable epiglottis, but i just cant seem to get the thing outa the way no matter what i do. But then somehow the attending steps in and bam, grade I view. Any other thoughts?

 

[Mister J]

Positioning is a big key. I've had one of my attendings tell me to take the extra pillows away as the head is too flexed and there will be difficulty with extending the head. I used to listen to him, but now I'm like "nah, I'm good" as I think the correct sniffing position helps me out more than extending the neck back and having to use more muscle to lift up the whole head off the pillow to see the cords. Just my opinion.

This is coming from another rookie, OP, but I had one preceptor teaching me to open the mouth using a scissors technique with my fingers. I had trouble getting that one to work.

Another preceptor taught me to extend the neck and let the airway open itself. This seemed to work better for me. I had less difficulty managing the mandible and getting the tongue out of the way.

 

[Planktonmd]

The most important thing to do is to always remind yourself that this is NOT an emergency, this is a 100% controlled situation and you have plenty of time to put the tube in, no one is going to die and no one is expecting you to intubate on your first attempt.
The most common reason why inexperienced people fail to intubate is anxiety.
If you preoxygenate a healthy patient correctly you can have 8-10 minutes of time to do your procedure, there is absolutely no rush.
Open the mouth as wide as you can with your right hand fingers in the right corner of the mouth, try to subluxate the jaw, you will feel it pop in most people if the muscle relaxant has been given enough time to work.
Slide your blade from the right side while gently moving the tongue out of the way. Don't start lifting until the tip of your blade has reached the right tonsil, now pull forward and upward, you should see either epiglottis or cords here.
If you see epiglottis then you might need to advance a little.
Always remember to relax and stay cool.

 

[Frank Rizzo]

The most important thing to do is to always remind yourself that this is NOT an emergency, this is a 100% controlled situation and you have plenty of time to put the tube in, no one is going to die and no one is expecting you to intubate on your first attempt.
The most common reason why inexperienced people fail to intubate is anxiety.
If you preoxygenate a healthy patient correctly you can have 8-10 minutes of time to do your procedure, there is absolutely no rush.

This is one of the biggest things i stress to the rotating med students.

 

[Intensivist]

l too at begining have had trouble with visualizing cords, blade too deep etc, but as you get over No. 10 things get quite good, and by No. 50 you get quite good, not to say that it's sufficient to be real good at it, most docs l've talked to say No. 100 being the magic no.
But after geting good with visualizing, l got some trouble with inserting the tube, to be more precise, visualizing the entrance in right hole. Got me to esophageal intubation, was so embarrassed, still am somewhat...

 

[BobBarker]

Its all about sweeping the tongue. You may think you are sweeping it adequately, but you are probably not. Concentrate on each and every step, and go nice and slow. Slow is smooth, smooth is fast.

 

[midazme]

i had this trouble, too, when i was starting out.

if your program allows you to use a glidescope, i suggest that you use that next time and have the anesthesia attending watch on the monitor exactly what you're doing. it could be that you're approach is off, that you're not moving the tongue just right, or that you're cranking on the teeth instead of pushing up and out. or you could be visualizing something that you mistaken for the cords.

good luck.

 

[Licoricestick]

i had this trouble, too, when i was starting out.

if your program allows you to use a glidescope, i suggest that you use that next time and have the anesthesia attending watch on the monitor exactly what you're doing. it could be that you're approach is off, that you're not moving the tongue just right, or that you're cranking on the teeth instead of pushing up and out. or you could be visualizing something that you mistaken for the cords.

good luck.

That's not actually much help - cause the proper technique with the glidescope is completely different to the proper technique with a MAC blade.

 

[dhb]

Its all about sweeping the tongue. You may think you are sweeping it adequately, but you are probably not. Concentrate on each and every step, and go nice and slow. Slow is smooth, smooth is fast.

Can someone explain to me the benefit of the tongue sweep i know it's emphasized but i don't pay much attention to it and i don't have a hard time intubating.

I agree with the video laryngoscope proposal most of the time the glottis is right there but people don't recognize it.

 

[powermd]

I would like to reiterate the point about positioning. No pillows with the head extended and an inexperienced anesthesia resident is a recipe for a very quickly sore arm, frustration, anxiety, and failure. Stick a pillow just under the shoulders, then another on top of that pillow to support the head. Now extend the head to give you a nice sniffing position. Now you can focus on sweeping the tongue correctly and sorting out all the pink tissues at the tip of your blade, because the lifting has been done for you by the pillows.

 

[Idiopathic]

Can someone explain to me the benefit of the tongue sweep i know it's emphasized but i don't pay much attention to it and i don't have a hard time intubating.

its quite possible you do it and dont realize it (re: tongue sweep) but try and stick a mac 3 blade down the middle of the tongue and you will likely find it pretty close to impossible to intubate. the blade is designed to come in on the right side of the mouth and naturally sweep the tongue over. it really only is something i have to think about when i have a really limited oral opening, it just becomes second nature after a few hundred intubations

 

[Idiopathic]

I would like to reiterate the point about positioning. No pillows with the head extended and an inexperienced anesthesia resident is a recipe for a very quickly sore arm, frustration, anxiety, and failure. Stick a pillow just under the shoulders, then another on top of that pillow to support the head. Now extend the head to give you a nice sniffing position. Now you can focus on sweeping the tongue correctly and sorting out all the pink tissues at the tip of your blade, because the lifting has been done for you by the pillows.

this is also a good point, i used to scoff at all the pillows but ive become more of a believer as the years have gone on.

another thing i do first is to grab the occiput and extend the neck with my off hand to a) open the mouth passively and b) get a feel for maximal extension, which gives me an idea of how flexible the neck is. i no longer scissor the mouth open unless this move doesnt work which also gives me a clue as to how difficult the laryngoscopy could be.

 

[waterhammer]

When inserting the tube, don't block your view with your right hand. You can insert the tube perpendicular to the long axis of the body and rotate it into its final position as you enter the trachea.

 

[Jay K]

After induction

1) Scissor open the mouth by
A) Holding middle finger of right hand extended in a horizontal fashion. With the midpoint of extended middle finger, push downwards on the right commissure of the patient's mouth until your finger is well into the mouth opening.
B) Now take the tip of your middle finger and brace upon lateral incisors of the maxilla. Then with the tip of the thumb of right hand, push downwards upon lateral incisors of mandible and sublux (push downwards on/open up) the jaw as far as possible.
C) Your middle finger and thumb of right hand should make an "X" shape bracing open the patient's mouth if you have scissored the mouth open properly.

2) Insert MAC blade from right side of mouth, near to your "scissor fingers" and sweep the tongue to the left. Your MAC blade should end it's position exactly midline in the patient's mouth. Make certain your blade is fully inserted (choose appropriate length beforehand).

3) Now take your right hand and place on patient's forehead. Use this hand to gently extend the neck atraumatically to "align your axis" appropriately.

4) Now lift directly upwards with your MAC blade (left hand). Because you have already aligned your axis, there is no need for wrist movement or "cranking on the teeth." You will not break teeth, nor will you catch the lip on teeth. There is no movement aside from upwards lifting of the blade and handle.

5) Now take your right hand and adjust the patient's airway along the cricoid cartilage to optimize your view (directing downwards/left/right). When you have attained the view you want, have the RN or attending hold the cricoid cartilage in place as you have it.

6) Intubate.

That is ONE method of intubating with a MAC blade and optimizing your view.

All the aforementioned advice is also good advice. Just pick and choose what you like.

You'll get it eventually.

 

[tucker27705]

I do exactly what Jay K outlines above, and it works great. I will add just a few comments, that have been made elsewhere, for emphasis.
Position the pt well. You will learn with time what this means. Essentially, if positioned well, you won't have to lift the pt's head with the blade, or hold it there with your belly or the nurse's/assistant's aid as you intubate.
This is a controlled situation and you have time.
Two days ago I took my first look with a Mac 3, then decided it needed to be changed for a Mac 4. There were no Mac 4's in the drawer. I told the nurse I'd be back in a minute. Strolled across the hall, unlocked the anesthesia cart, found a Mac 4, walked back and then intubated the pt. Sa02 never went below 100. If you know you can mask the pt and have preoxygenated well, you have plenty of time. Relax as much as you can and do what you need to to.

I remember clearly the moment I "got it." An attending told me to put the blade in at about 45 degrees, then turn and sweep that tongue out of the way. I never looked back.

Tuck

 

[Bohica]

I'm having similar problems that the original poster has been experiencing. I have been attempting intubations with a MAC 3 blade and can successfully get the tip of the blade into the vallecula and can visualize the epiglottis over the blade but cannot visualize the vocal cords. I then try to move the blade in a upward direction (parallel to the handle) but the epiglottis will not move out of the way to allow visualization of the vocal cords. I have been given similar advice to what I've read in this thread EXCEPT I have been told by numerous CNRAs that when using a MAC blade you begin mid-line and to not sweep the tongue, instead that I should begin with insertion of the blade mid-line. They claim that the tongue should only be swept from right to left when using a straight Miller blade. I have also read that the patients head should be at the level of the xiphoid process of the person attempting intubation. I am 6'4'' and feel I may be out of position to the extent I am not getting a clear line of sight. I will try sweeping the tongue tomorrow and see if that makes any difference. Any other specific tips that have not been covered so far would be greatly appreciated.

 

[proman]

I have been given similar advice to what I've read in this thread EXCEPT I have been told by numerous CNRAs that when using a MAC blade you begin mid-line and to not sweep the tongue, instead that I should begin with insertion of the blade mid-line. They claim that the tongue should only be swept from right to left when using a straight Miller blade.

Are you sure you heard/remembered correctly? This advice is the exact opposite of what you should do. And, as a medical student, you really shouldn't be learning this stuff from non physicians.

 

[WholeLottaGame7]

Are you sure you heard/remembered correctly? This advice is the exact opposite of what you should do. And, as a medical student, you really shouldn't be learning this stuff from non physicians.

2nd.

Also, I've found that in general (and compared to mannequins), intubating takes far more force than it feels like it should. Especially in those patients that are $2.50 and up. Of course, starting out, you're always deathly afraid of hurting someone.

 

[lushmd]

Also, I've found that in general (and compared to mannequins), intubating takes far more force than it feels like it should.

Actually, I disagree with this statement. If you've optimized positioning etc..., with good technique it usually doesn't require much force (and much less than what is needed for a mannequin, at least the ones that we have here).

 

[Bohica]

Are you sure you heard/remembered correctly? This advice is the exact opposite of what you should do. And, as a medical student, you really shouldn't be learning this stuff from non physicians.

Proman,

Thanks for the response. I definitely heard correctly. This morning when attempting an intubation with a MAC 3 blade I began to sweep the tongue to the left by starting off in the right corner of the patients mouth. I was immediately told by 2 CRNAs watching that this was incorrect technique and MAC blades should be positioned starting off mid-line of the tongue due to the curvature of the MAC blade allowing you to follow the tongues natural curve making sweeping of the tongue unnecessary.

I agree with your point regarding learning from non-physicians but unfortuantely I am rotating at a hospital that has only 1-2 anesthesiologists present at any one time and he/she mainly supervises the 8 -12 CRNAs or the open heart cases and is rarely, if ever, present for the intubations.

Thanks again for the response and I will be sure to follow this threads advice tomorrow.

 

[lushmd]

Bohica, regardless of what these CRNAs told you, its wrong. As described previously, the MAC blade has a flange with which one is intended to sweep the tongue to the side whereas the Miller, which lacks this flange, is designed to be inserted straight down the middle without sweeping the tongue (although some will approach from the corner of the mouth, but that's not really pertinent to this discussion).

General tips:

(1) Proper positioning is key, especially in obese patients. Optimize the sniffing positioning using pillows, blankets, etc... In larger patients, some reverse trendelenberg can be helpful. As you posted, having the top of the pt's head somewhere around your xyphoid process is a reasonable rule of thumb.

(2) Pre-oxygenate.

(3) Learn how to mask ventilate. If you adequately pre-oxygenate and can mask ventilate a patient, you're more likely to be given multiple attempts at intubation than otherwise.

(4) Tilt the patient's head back, clear the lips from the teeth, and open the mouth.

(5) Insert the MAC blade (its easier to learn with the MAC, once you become proficient with this blade then start practicing with the Miller blade etc...) in the right side of the mouth, sweep the tongue to the left with the blade's flange until the blade is in the midline. Then advance the blade until you see the epiglottis and gently lift up and away (i.e. with the laryngoscope handle extended towards a point at the intersection of the ceiling and opposite wall) avoiding trauma to the teeth. At this point, you should be able to visualize the vocal cords. If not, stay calm and try to figure out what to do differently. If asked what you see, be honest.

(6) Practice (lots). Like any skill, it takes experience to become proficient. Try not to get frustrated.

 

[Arch Guillotti]

agree, I always thought the mannequins were harder to intubate than most real live persons. Shouldn't take too much force most of the time on live persons.

Actually, I disagree with this statement. If you've optimized positioning etc..., with good technique it usually doesn't require much force (and much less than what is needed for a mannequin, at least the ones that we have here).

 

[proman]

Proman,

Thanks for the response. I definitely heard correctly.

Well so much for anyone being able to learn monkey skills. What kind of hospital is this? And, as an aside, before you decide whether or not to do anesthesiology, you should rotate at a real training facility.

Here's what I tell the med studs:

1) Position. As others have said, it's key. Everyone develops their own preference but I've found that table height is the biggest determinant of whether I'll struggle or not. You're a foot taller than me, so obviously the tables need to be different. I like having the head around my xiphoid with a Mac, a little higher with a Miller

2) Preoxygenate, masking. Echo what others have said. Many novices think the patient will die if they don't put the tube in ASAP. You have time. Relax, hold the handle loosely but firmly. Do it right.

3) Open the mouth. Good scissoring will move the jaw and the lower lip out of the way.

4) Laryngoscopy. The goal isn't to put most of the blade in. Don't advance all the way then pull back. It's poor technique (but an effect rescue technique). I put the (Mac) blade in along the right gutter with the handle 45 degrees to the right. As I advance the tip of the blade to the base of the tongue, in one smooth motion, my sweep catches the tongue with the flange along the left of the Mac blade and returns my handle to the midline. At this point, I advance with slight upward/forward motion (the vector of the force should be to the far wall's ceiling) until I see the epiglottis. At that time, I continue to advance until the vallecula is engaged. If I don't see the cords at this point, I use more force, maintaining the vector to the far wall's ceiling. This usually works quite well. And remember, laryngoscopy is meant to identify structures of the pharynx/hypopharynx/glottis.

Hope this helps, it makes a bit more sense when I actually demonstrate what I mean.

 

[Jay K]

I have also read that the patients head should be at the level of the xiphoid process of the person attempting intubation. I am 6'4'' and feel I may be out of position to the extent I am not getting a clear line of sight.

I like having the head around my xiphoid with a Mac, a little higher with a Miller
\

When mask-inducing peds patients, I do so sitting down. Then since I'm already sitting (also while awaiting the PIV by RN while I manage the airway), I go ahead and intubate sitting as well. Nobody says you can't sit down for adults either. Why the hell not? (Aside from ill-informed and ill-trained CRNA's giving you the stinkeye for doing so - screw 'em... how do you mess up the fundamentals of inserting a MAC blade? Idiots...).

 

[n2b8me]

😉

 

[omniatlas]

After induction

1) Scissor open the mouth by
A) Holding middle finger of right hand extended in a horizontal fashion. With the midpoint of extended middle finger, push downwards on the right commissure of the patient's mouth until your finger is well into the mouth opening.
B) Now take the tip of your middle finger and brace upon lateral incisors of the maxilla. Then with the tip of the thumb of right hand, push downwards upon lateral incisors of mandible and sublux (push downwards on/open up) the jaw as far as possible.
C) Your middle finger and thumb of right hand should make an "X" shape bracing open the patient's mouth if you have scissored the mouth open properly.

http://www.youtube.com/watch?v=5J3J38se3TQ&playnext_from=TL&videos=lguWXMkmbrE

 

[WholeLottaGame7]

agree, I always thought the mannequins were harder to intubate than most real live persons. Shouldn't take too much force most of the time on live persons.

Maybe this is institution-specific. There have occasionally been some tough mannequins, but for most of them it seems like you get the blade in, lift up a smidge and the anatomy is all perfectly sitting right there. When in reality, patients might be obese, or more anterior, and it takes a little more work, especially to get a grade I view.

I agree, positioning and technique is key, and if you feel like you're about to rip the jaw off, it's probably not a matter that is resolved by more force.

 

[proman]

When mask-inducing peds patients, I do so sitting down. Then since I'm already sitting (also while awaiting the PIV by RN while I manage the airway), I go ahead and intubate sitting as well. Nobody says you can't sit down for adults either. Why the hell not? (Aside from ill-informed and ill-trained CRNA's giving you the stinkeye for doing so - screw 'em... how do you mess up the fundamentals of inserting a MAC blade? Idiots...).

Funny because I've only seen CRNAs intubate sitting (and failing). The mechanics just don't work for me, and our chairs aren't that trustworthy.

 

[urge]

while awaiting the PIV by RN while I manage the airway...

Interesting. Do you work by yourself? What happens when the RN cannot get the iv?

 

[heathermed]

hello everyone!!!

The sweeping the tongue thing REALLY WORKS!!! I started doing that and I was actually able to see the epiglottis more clearly. The first few times I still wasn't able to get it, but at least I knew what I was going for. And then, I FINALLY GOT IT!!! I was on cloud 9!!! I got about 3 out of the next 7 intubations. I'LL TAKE IT!!! I think this is definitely one of those skills that you just need to keep doing over and over again to be good.

THANK YOU VERY MUCH FOR EVERYONE's HELP! I truly appreciate it!

 

[Jay K]

Interesting. Do you work by yourself? What happens when the RN cannot get the iv?

I'm not certain I understand the question, but we're an MD heavy group- we do our own cases for the most part without CRNAs if that's what you mean by working by myself. So in ped cases the cirulator does the iv and rectal meds while I'm managing the airway in mask inductions. It's been rare that they can't get an IV. If the RN needs help, she can bend the arm back towards me; I continue to mask with left hand and insert IV with my right.

 

[Sergio99]

Hello,

I have to disagree with one detail: scissor-opening the mouth is a thing of the past. When I say a thing of the past, I don't mean that it is not done any more, but that it shouldn't be done any longer. I know that everybody else besides me does it that way, all my coworkers do it that way, every residency training program still teaches it that way, every textbook still teaches it that way. But it should not be that way, NO, NO, NO. You should not have to stick your fingers in anybody else's mouth. I have not done it in the last twenty years, and it is not needed. Once you give the relaxant and wait for it to work, you tilt the head of the patient back and the mouth opens on its own. If it doesn't, you just help it with the little finger of your left hand while you are holding the laryngoscope with the rest of your hand. Once you stick the scope on the right side of the tongue, you start advancing it, and when you see the tonsillar pillar move medially and keep advancing. Soon you see the epiglottis and you are in shape. Then you can use the over-the-epiglottis technique or the under-the-epiglottis technique, whichever way you like better, and it doesn't matter whether you are using a Mac or a Miller blade.

I know you are all going to think I am crazy, as everybody does, especially my coworkers, when I tell them not to stick their fingers in the patient's mouth, because they have always learned it that way, but the fact is that I have never needed to do that in over twenty years and many thousands of patients. Of course I have had my share of difficult intubations, but none having to do with scissor-opening of the mouth or not.

When we had the AIDS scare in the mid-1980s and learned more about hepatitis C, and all the other nice infections that can kill you, I decided to try intubating without sticking my fingers in the patient's mouth and it worked well, so I never went back to the "old" technique.

Try it, you will see that it works wonderfully. You will never need to scissor-open the mouth again. And when you finish intubating, don't make the dirty blade touch the handle of the laryngoscope: put it in a towel and send it for cleaning and sterilizing.

The same goes for LMAs: you don't need to stick your fingers in the patient's mouth.

Greetings

 

[urge]

Hello,

I have to disagree with one detail: scissor-opening the mouth is a thing of the past. When I say a thing of the past, I don't mean that it is not done any more, but that it shouldn't be done any longer. I know that everybody else besides me does it that way, all my coworkers do it that way, every residency training program still teaches it that way, every textbook still teaches it that way. But it should not be that way, NO, NO, NO. You should not have to stick your fingers in anybody else's mouth. I have not done it in the last twenty years, and it is not needed. Once you give the relaxant and wait for it to work, you tilt the head of the patient back and the mouth opens on its own. If it doesn't, you just help it with the little finger of your left hand while you are holding the laryngoscope with the rest of your hand. Once you stick the scope on the right side of the tongue, you start advancing it, and when you see the tonsillar pillar move medially and keep advancing. Soon you see the epiglottis and you are in shape. Then you can use the over-the-epiglottis technique or the under-the-epiglottis technique, whichever way you like better, and it doesn't matter whether you are using a Mac or a Miller blade.

I know you are all going to think I am crazy, as everybody does, especially my coworkers, when I tell them not to stick their fingers in the patient's mouth, because they have always learned it that way, but the fact is that I have never needed to do that in over twenty years and many thousands of patients. Of course I have had my share of difficult intubations, but none having to do with scissor-opening of the mouth or not.

When we had the AIDS scare in the mid-1980s and learned more about hepatitis C, and all the other nice infections that can kill you, I decided to try intubating without sticking my fingers in the patient's mouth and it worked well, so I never went back to the "old" technique.

Try it, you will see that it works wonderfully. You will never need to scissor-open the mouth again. And when you finish intubating, don't make the dirty blade touch the handle of the laryngoscope: put it in a towel and send it for cleaning and sterilizing.

Greetings

I don't have your years of experience but I never stick my fingers in the mouth either. I learned to intubate little by little under medicine residents during my internship. Never put my fingers in because half of them were awake (pretty brutal intubations). When I started anesthesia I had to do the scissors technique because that's what my attendings wanted to see. One day I knocked a lose molar out of some guy prying open his mouth. Never again have a used the scissors.

 

[Sergio99]

I don't have your years of experience but I never stick my fingers in the mouth either. I learned to intubate little by little under medicine residents during my internship. Never put my fingers in because half of them were awake (pretty brutal intubations). When I started anesthesia I had to do the scissors technique because that's what my attendings wanted to see. One day I knocked a lose molar out of some guy prying open his mouth. Never again have a used the scissors.

Great! That makes two of us.

 

[Intensivist]

how many of you take laryngoscope by the angle of blade and handle? l've seen docs holding it like that, and thought wtf? l thought only inexperienced docs (non anaesthetitsts) are doing it this way?

 

[dhb]

the fact is that I have never needed to do that in over twenty years and many thousands of patients. Of course I have had my share of difficult intubations, but none having to do with scissor-opening of the mouth or not.

The same goes for LMAs: you don't need to stick your fingers in the patient's mouth.

Greetings

Totally agree i never put my fingers in a patient's mouth except when the freaking NG tube doesn't want to go in.

 

[Sergio99]

Hello,

Totally agree i never put my fingers in a patient's mouth except when the freaking NG tube doesn't want to go in.

With urge, dhb and myself, it makes three. Maybe we should think up a way of publishing this philosophy and technique of intubation, for the good of the whole medical profession. I just doubt that a journal will accept such a simple manuscript.

Greetings

 

[Jay K]

I've put my gloved fingers on enough jagged meth-rotten teeth to agree that not putting one's fingers in the mouth is probably a good idea, but I'll probably not change. And if it makes you feel any better, I had one attending who never placed fingers in the mouth either (including LMA's). I'm wondering if it isn't you, "Sergio."

 

[Sergio99]

I've put my gloved fingers on enough jagged meth-rotten teeth to agree that not putting one's fingers in the mouth is probably a good idea, but I'll probably not change. And if it makes you feel any better, I had one attending who never placed fingers in the mouth either (including LMA's). I'm wondering if it isn't you, "Sergio."

I doubt, Jay K. In the last 30 years I have only worked in places without anesthesia residents. I have never been an attending in a training program. Thank you for your story: that makes four. I am sure there must be many more around.

Greetings

 

[omniatlas]

Hello,

I have to disagree with one detail: scissor-opening the mouth is a thing of the past.

No, you are correct. I asked one of the registers about the technique and he said you shouldn't necessarily have to do that, for exactly the same reasons you've mentioned.

 

[Planktonmd]

I doubt, Jay K. In the last 30 years I have only worked in places without anesthesia residents. I have never been an attending in a training program. Thank you for your story: that makes four. I am sure there must be many more around.

Greetings

It doesn't matter how you open the mouth, actually tilting the head back will effectively open the mouth for you enough (in most patients) to insert your blade, but if you have a patient with an anterior airway it really helps if you could subluxate the mandible before you insert the blade and the easiest way to achieve that maximal mouth opening is with the fingers in the the right corner of the mouth.
To say that a certain technique is a "thing of the past" is a strong statement in a business where every thing can be done at least 10 different acceptable ways.

 

[Depakote]

To those of you that don't use the scissor technique, what do you do when the neck is immobilized?

 

[countingdays]

To those of you that don't use the scissor technique, what do you do when the neck is immobilized?

Open the mouth with the laryngoscope blade + maybe with a little push on the chin to get things started if the mouth is too closed to get the blade in.

 

[Idiopathic]

how many of you take laryngoscope by the angle of blade and handle? l've seen docs holding it like that, and thought wtf? l thought only inexperienced docs (non anaesthetitsts) are doing it this way?

only in children

 

[Idiopathic]

btw sergios technique is exactly what i describe above and what i teach. i think that it works great except for the unstable c-spine in which case i will put a tongue depressor in until i can insert the blade