I cannot intubate!!!

[Annoyances]

I am a new CA1 started in July and lord I cannot intubate! I am getting seriously worried and my attendings are like frustrated with me. I just don't ever get it I've had about 11 tries thus far that required intubation and I only successfully got 1 ( and my attendings are totally frustrated keep making nasty remarks. One guys was like WHAT HAVE U BEEN DOING THE PAST MONTH!!! WHAT THE HELL IS WRONG WITH U WHY CAN"T U INTUBATE!!! Its getting seriously scary for me now I feel like perhaps they will ask me to leave... Something always happens and I end up not being able to intubate. Either I cannot see the cords properly or I cannot push the tube in or cannot move the epiglottis there is always something. Its very discouraging and these attendings are not very friendly at all. It really sucks.

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[DreamMachine]

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[powermd]

I am a new CA1 started in July and lord I cannot intubate! I am getting seriously worried and my attendings are like frustrated with me. I just don't ever get it I've had about 11 tries thus far that required intubation and I only successfully got 1 ( and my attendings are totally frustrated keep making nasty remarks. One guys was like WHAT HAVE U BEEN DOING THE PAST MONTH!!! WHAT THE HELL IS WRONG WITH U WHY CAN"T U INTUBATE!!! Its getting seriously scary for me now I feel like perhaps they will ask me to leave... Something always happens and I end up not being able to intubate. Either I cannot see the cords properly or I cannot push the tube in or cannot move the epiglottis there is always something. Its very discouraging and these attendings are not very friendly at all. It really sucks.

Read the intubation thread under the sticky "procedural techniques" for tips on improving airway skills.

The best single piece of advice I can give is to position the patient well (sniffing position). Do this by having an axillary roll under the back, and their head propped up on a pillow. If your attending is being expeditious, this helpful technique is often ignored. You can correct for this by lifting the patient's head with your non-laryngoscope (right) to try to get a better view of the cords, when you see them, hold the head in position with the laryngoscope. Alternatively, you can just lift the whole head up with the scope, but your arm will become fatigued quickly if you have trouble finding the cords.

Your problem with slipping the tube throught the cords may be due to poor styletting of the tube. If you're going to use a stylet the traditional way (put the whole thing, stylet and tube through the cords, then slip the stylet out), make sure the stylet has a good curve to it, not just a hockey stick. It can be more difficult to push a hockey stick through the cords than a curved tube. At Columbia, some people use a technique where they make a hockey stick, but twist the stylet end around to form a handle that you can push the tube off of with one hand. Tough to explain without a visual, but that technique works well for the easier airways.

 

[hope2bnmd!]

just try your best, it takes longer to learn the skill for some than others. i dont think a residency can kick you out b/c u take a longer time than others to learn how to intubate. if you can work with some attendings on the staff who u know to be patient, and good teachers. good luck, and im sure you will get a hang of it soon.

 

[Laryngospasm]

I am a new CA1 started in July and lord I cannot intubate! I am getting seriously worried and my attendings are like frustrated with me. I just don't ever get it I've had about 11 tries thus far that required intubation and I only successfully got 1 ( and my attendings are totally frustrated keep making nasty remarks. One guys was like WHAT HAVE U BEEN DOING THE PAST MONTH!!! WHAT THE HELL IS WRONG WITH U WHY CAN"T U INTUBATE!!! Its getting seriously scary for me now I feel like perhaps they will ask me to leave... Something always happens and I end up not being able to intubate. Either I cannot see the cords properly or I cannot push the tube in or cannot move the epiglottis there is always something. Its very discouraging and these attendings are not very friendly at all. It really sucks.

Am I reading you right that youve only had about eleven tries total? Thats probably a lot of the problem, you just need more experience. Also work on the sniffing position, and using the blade to "lift" the epiglottis, either with a mac in front or a miller or wisconsin behind. Tell your staff to get you more intubations, thats a crime to only have eleven after 6 weeks.

 

[Lonestar]

positioning is key. I myself am a MAC man. It generally takes about 50 intubations for most people before they start feeling comfortable with most airways. So, get on it. Figure out which attendings give you some leeway and practice with them. I had a 50% success ratio when i first started out and most of those people that I intubated were edentulous. Just keep at it and good luck.

 

[Sammich81]

I'm an MS4. Something an attending showed me that helped a lot is this: in addition to putting the head in the sniff position, put one or two folded up blankets under their head/shoulders. For some reason it seems to move away all the soft tissue that collapses in front of the cords. Also he prefers the miller. The couple I did with him were effortless. Then again they could have been just easy airways, because I've struggled with a mac and a miller in some folks.

 

[Laryngospasm]

I'm an MS4. Something an attending showed me that helped a lot is this: in addition to putting the head in the sniff position, put one or two folded up blankets under their head/shoulders. For some reason it seems to move away all the soft tissue that collapses in front of the cords. Also he prefers the miller. The couple I did with him were effortless. Then again they could have been just easy airways, because I've struggled with a mac and a miller in some folks.

This works well for extreme fatties, it is NOT necessary for most people. The miller is also HARDER for newbies. Please be carefull giving advice when you dont know what you are talking about.

 

[DreamMachine]

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[CambieMD]

If you are not deep enough into the vallecula (sp?) you won't get a good lift of the esophagus and visualization of the cords. May try going a little deeper with your blade.

Also, sometimes all you need is a good strong lift of the blade and everything comes into view.

I agree with the above post. When I started my CA-1 year I was successful with the mac but did not always obtain a good view of the larynx. Advancing into the vallecula then lifting up helps a lot.


I was told that it takes 70 intubations to begin to feel comfotable with a particular blade.

I think that the mac is the best blade to start with. Towards the end of last year I started using the miller. Sometimes controlling the tongue is a problem. I try to sweep it over to the left.

Becoming skilled with intubating involves trying over and over.


Cambie

 

[HomerSimpson]

All good advice. I may also add... Whichever pharmacologic agents you are using make sure that they are in full effect before you start your laryngoscopy. Make sure the patient is deeply anesthetized and fully relaxed before attempts. A patient who is suboptimally relaxed can be a bear to intubate. The old story goes... resident tries to intubate and fails... attending intubates 3 min later without any trouble. Is it experience, skill? yeah.. but also the relaxant just took effect. keep at it man.

 

[Monty Python]

I am a new CA1 started in July and lord I cannot intubate! I am getting seriously worried and my attendings are like frustrated with me. I just don't ever get it I've had about 11 tries thus far that required intubation and I only successfully got 1 ( and my attendings are totally frustrated keep making nasty remarks. One guys was like WHAT HAVE U BEEN DOING THE PAST MONTH!!! WHAT THE HELL IS WRONG WITH U WHY CAN"T U INTUBATE!!! Its getting seriously scary for me now I feel like perhaps they will ask me to leave... Something always happens and I end up not being able to intubate. Either I cannot see the cords properly or I cannot push the tube in or cannot move the epiglottis there is always something. Its very discouraging and these attendings are not very friendly at all. It really sucks.

In addition to proper sniffing position and blade skills, it's important to have the pt's forehead at the proper height in relation to your body.

I think it's Morgan and Mikhail (maybe Barash) which says the pt's forehead should be at your manubrium to properly align your eyeballs with the pt's airway anatomy. It also maximizes the mechanical advantage of your hand and arm. I sometimes rest my left elbow on the OR table next to the pt's head when intubating and use nothing but gentle wrist action to move the laryngoscope.

 

[jwk]

If you are not deep enough into the vallecula (sp?) you won't get a good lift of the esophagus and visualization of the cords. May try going a little deeper with your blade.

Also, sometimes all you need is a good strong lift of the blade and everything comes into view.

epiglottis.

 

[Monty Python]

.........Also, sometimes all you need is a good strong lift of the blade and everything comes into view.

This is not a sexist comment, but some petite ladies with limited upper body strength sometimes have trouble with this particular aspect.

Those same individuals usually benefit from a pencil-thin laryngoscope handle. It's rare to see hospital-owned handles apart from the standard 2 C-cell ones. The pencil-thin handles take AA batteries and can make all the difference for folks with smallish hands. A recommended tax-deductible investment.

Also suggested: a stubby handle for use on those female patients generously endowed with huge breasts.

http://www.miami-med.com/ADC_battery_handles.htm

 

[VolatileAgent]

I am a new CA1 started in July and lord I cannot intubate! I am getting seriously worried and my attendings are like frustrated with me. I just don't ever get it I've had about 11 tries thus far that required intubation and I only successfully got 1 ( and my attendings are totally frustrated keep making nasty remarks. One guys was like WHAT HAVE U BEEN DOING THE PAST MONTH!!! WHAT THE HELL IS WRONG WITH U WHY CAN"T U INTUBATE!!! Its getting seriously scary for me now I feel like perhaps they will ask me to leave... Something always happens and I end up not being able to intubate. Either I cannot see the cords properly or I cannot push the tube in or cannot move the epiglottis there is always something. Its very discouraging and these attendings are not very friendly at all. It really sucks.

this reeks of a troll post.

 

[pratik7]

See if there is a nearby medical school that has dummies you can practice on. Its prob easier when there isnt someone breathing down your neck and you can work at your own pace.

 

[DreamMachine]

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[DreamMachine]

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[VolatileAgent]

Only 11 tries so far?

exactly. i did 11 intubations my first week. either someone's trolling, or they are in a REALLY crappy program.

 

[Tenesma]

it is funny how intubating somebody seemed second nature after about 6 months of CA-1... you really start proving your metal when you are on the airway team running to codes and shoving tubes down without any supervision whatsoever... i miss those days --- not all the time, but every once in a while...

and dude if i had a resident who couldn't intubate after 1 month of anesthesia, that would be a BIG issue... better start figuring out a solution quick... or ask for a cystoscopy room or EGD room and intubate everybody instead of using LMAs or MAC...

 

[Annoyances]

Troll post? Hmmm well first of all yeah my program likes to criticize a lot and not really teach much. in term of the 11 attempts yeah that is mostly all the tries I was allowed at that time its is a pretty crappy program they kept putting me in MAC rooms which did not require intubations so yeah I only got 11 tries. LOL in the month August I got a few more tries putting me up only to 8 intubations. Then I got a week vacation (not really by choice just given it by lottery system) so about to go back to work and hopefully get more intubations. Yes I agree its a major problem when you've completely two months of a residency and are criticized all the time yet no one really offers much help and u now only have 8 intubations under ur belt. I am starting to think perhaps I should try and go back to internal medicine or attempt to switch to another field. I've been extremely unhappy at my program then again a lot of the other residents seem miserable as well and no one ever says anything positive about it. There are a few nice attendings but the grand majority are just criticizers not really much about teaching.

 

[CambieMD]

Seek out more airway experience. Speak to attendings who enjoy teaching and ask for pointers. Look at what others do when they are intubating.
Take your time to locate important landmarks before you attempt to pass the ETT.

Do not switch to another fiel, you would live to regret it.
I had no trouble intubating but I felt that I did not get my cases started with enough ease. I spoke to an attending that I liked and he worked with me. I helped others strart their cases if I had down time. That took care of the problem in a few weeks.

Putting in a little extra effort now will pay off later on.You basicly direct your own learning. Tell your attendings what you need and some of them will give you the guidance that you are looking for.

Feel free to pm me.

CambieMD

 

[meddog1]

Work with head-positioning and try using different Mac blades as a rookie. If you have a simulator, then practice (although I think it doesn't ever really replicate the real thing). Stay late and work with a senior you trust to mentor you while he/she is doing call, or working later than you. Make sure you are looking anterior enough. You will get it. It's just like threading a big needle.

 

[supahfresh]

dont give up. i'm sure there is at least one person in your department that cares. find out who makes the schedule and politely ask for GA cases. I think that is a very resonable request. Everyone goes through this in the beginning.

 

[SleepIsGood]

Use a MAC blade. Also in my opinion, do not put the pt into the sniffing position. I find it easier to scissor open the mouth, stick the blade in on the right. Then sweep the tongue. Then in one motion pull forward with the blade (with left hand) and put pt into sniffing positing with right hand. While you do this you are gradually following the curve of the tongue and will see the cords drop in front of your eyes. Works like a charm for me, it's a neat trick a resident taught me and I have used it to intubate pts without missing even one now. Try it.

 

[lvspro]

Hi
I'm not too sure how much I can help, but I'll throw my $0.02 in.
Every time I would miss an intubation on my rotations, the first place I'd go would be to the sim lab, or the dummy. I'd try to visualize where I was at, and then correct it accordingly on the sim. I found that by making a mental note of any misses, that I could quickly remedy them with a few dry runs. Anyhow, I hope you're really able to get you're groove, and start nailing those tubes.
btw, you'd be amazed at how much a daily airway review, and some confidence have on hitting even the most difficult airways.
GL