I hate video laryngoscopy.

[RustedFox]

Yep.

Granted, I've only used it a handful of times, but we have the plastic videoscope blade and then the totally detached screen that's 'held' by another individual, or just placed on the bedside. Screen is okay, but the tube over the manufacturer-provided stylet.... garbage. Can't manipulate it anywhere, can't bend it as you go, its rigid as all hell and pulls the tube out along with it when you try to pull the stylet to connect the BVM.... aerwu9paodsica;lcn.

This is largely just me complaining. Feel free to comment/criticize.

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[Rendar5]

1st, don't get a great view, if it looks super good, pull back a bit. the close you are to the cords with the camera the less room to maneuver
2nd, don't pull the stylet yourself. rigid stylets in my experience pull the tube if you try to do it solo. Hold the tube in place and have someone else pull the stylet so you don't dislodge.
3rd don't go in like you normally would with the stylet, go in horizontally until the tube is near the cords, then flip your stylet vertical. this will usually end up inserting the tube right where you want it.
4th, addendum to 2nd: once the stylet is within the cords, it's hard to advance because It won't straighten. What you do is have someone hold your rigid stylet in place and you advance the tube forward.

The motor skills are different between VL and DL, you run into trouble when you assume it's the same.

 

[Arcan57]

They have VLs that don't have the Glidescope's curve (C-Mac being one of the most common and expensive alternatives) and tend to work better for docs that didn't train with VL extensively. As Rendar said, you're aiming for the view were the cords seem a little bit too far away. Inserting the ETT/rigid stylet in midline with this view almost always thrusts the tube just past the cords and into the anterior trachea. Then have your RT hold the stylet and pull back slowly as you advance the ETT (I often find I can't advance if the stylet is held in place completely). It's somewhat frustrating because I often find I'm blind during this part of the intubation because I take my hands off the scope to have more motor control during the advancement (because I don't quite trust the RT to pull back at the appropriate speed). So I'll have seen it go in the cords but when the patient sats start dropping because of the lag time inherent in using a peripheral pulse ox, I'm always worried I backed the stylet out too far before advancing. I've never had that happen yet, but I can see it happening.

 

[Tiger26]

Are you able to practice in the OR? Rendar and Arcan have good tips.

Also, when you insert it, first don't look at the screen and just focus on getting the blade in the mouth. Then look at the screen as you advance to the cords. When you have a good view, stop looking at the screen as you focus on putting the ETT in the mouth. Now look at the screen.

 

[OCDEMS]

Sort of related, but maybe good for the EM docs to know, if you didn't already: VL is becoming big business in the prehospital world. There are two competing schools of thought. Some people are pushing for a move to VL, whenever possible. Others are arguing for the preservation of DL as a first-line skill to prevent degradation of a skill where there is already infrequent opportunities to perform it in the prehospital arena (where I personally stand). From the standpoint of serious players, Glidescope seems to be leading the pack. In order of cool new toys to watch in the next 10 years for EMS: mechanical CPR, video laryngoscopes, prehospital ultrasound. My understanding is that the latter will have a big marketing push in the coming years, particularly as Physio and other manufacturers investigate including it into their monitors.

 

[Arcan57]

Sort of related, but maybe good for the EM docs to know, if you didn't already: VL is becoming big business in the prehospital world. There are two competing schools of thought. Some people are pushing for a move to VL, whenever possible. Others are arguing for the preservation of DL as a first-line skill to prevent degradation of a skill where there is already infrequent opportunities to perform it in the prehospital arena (where I personally stand). From the standpoint of serious players, Glidescope seems to be leading the pack. In order of cool new toys to watch in the next 10 years for EMS: mechanical CPR, video laryngoscopes, prehospital ultrasound. My understanding is that the latter will have a big marketing push in the coming years, particularly as Physio and other manufacturers investigate including it into their monitors.

Given the dismal first-pass success of pre-hospital airways (I'm aware there are isolated pockets of exceptions), I think it's even more difficult to justify making a stand for DL based on it being a necessary skill than in the hospital setting. I'd also be very interested in seeing a study of BVM vs. VL in the pre-hospital setting. In terms of the innovations you mention, with the exception of mechanical CPR, I don't see them being universally adopted. While the price point for disposable VL is dropping, a lot of FDs aren't going to have the money to upgrade their entire system. Same with U/S, plus developing competence in U/S for it's life saving applications would require substantial training costs. For systems with prolonged transport times as the standard it makes sense, but in an urban setting it's not going to change management without tacking on significant scene time. I could see some protocol were hypotensive blunt trauma patients went to the OR from EMS stretcher with positive FAST, but getting buy-in from the trauma surgeons would be significantly trickier than cardiologists for STEMIs.

 

[OCDEMS]

Given the dismal first-pass success of pre-hospital airways (I'm aware there are isolated pockets of exceptions), I think it's even more difficult to justify making a stand for DL based on it being a necessary skill than in the hospital setting. I'd also be very interested in seeing a study of BVM vs. VL in the pre-hospital setting. In terms of the innovations you mention, with the exception of mechanical CPR, I don't see them being universally adopted. While the price point for disposable VL is dropping, a lot of FDs aren't going to have the money to upgrade their entire system. Same with U/S, plus developing competence in U/S for it's life saving applications would require substantial training costs. For systems with prolonged transport times as the standard it makes sense, but in an urban setting it's not going to change management without tacking on significant scene time. I could see some protocol were hypotensive blunt trauma patients went to the OR from EMS stretcher with positive FAST, but getting buy-in from the trauma surgeons would be significantly trickier than cardiologists for STEMIs.

I don't completely disagree with you, but I will say that there is significant controversy (at least among EMS providers) about the studies showing poor first-pass success. To your comment regarding BVM: there was a study in SCA and it found the BVM group had better neurologic outcomes. http://www.ncbi.nlm.nih.gov/pubmed/23321764. Good thought. With that said, the reasons for this probably vary. The Wang studies out of Pittsburgh have been criticized because they took place in PA, where EMS is largely rural and funded in all sorts of crazy, non-sustainable ways. Someone will argue with me, but it's largely true. In my own experience, I've rarely ever worked with anyone who had the lack of exposure that he described in one of his studies ( I think was 1-2 attempts/yr). Most of our paramedics obtained at least 5-6 intubations a year with overall success in the 90% range and a first-pass rate in the 80th percentile. Among experienced paramedics I would venture to say it was well over 90% and with higher total numbers. Not ED quality, admittedly. I have never seen an unrecognized esophageal intubation after the advent of prehospital EtCO2 monitoring. Never. In great systems with highly educated paramedics, available intubation rotations, an involved medical director, and good QA I'd say the rate is comparable (elite, competitive programs and flight EMS). Again, rare.

There is also some debate about the neurologic outcomes in intubation during SCA. I personally used to work in a system where intubation took priority in arrest and, honestly, I still believe it affected outcomes. Placing undue and unnecessary pressure for early success at the expensive of high-quality CPR is probably the causative agent of the poor outcomes, not the intubation itself. Only recently did the emphasis go to "high-performance" CPR and intubation before transport.

I definitely think you'll see adoption of ultrasound in well-funded systems, if only because I've already seen an entire industry starting to provide it. GE is already dabbling in the market and Physio, Zoll, and Philips wants to sell the next great thing. Capitalism will win here. Apparently, according to my old monitor rep, at least one manufacturer is already developing a future monitor with included ultrasound and there is a CE industry upstarting to provide 3 day and 1-week ultrasounds courses. As part of the new National Scope of Practice update from the old paramedic to the new, every paramedic in my system received a basic ultrasound in-service, including the basics of a FAST exam. I've read about systems that teach everything from the basics of kidney stone identification to fractures in the larger long bones. I'm not speaking to the efficacy of any of this, and as someone who recognizes there are entire fellowships in ultrasound, I myself questioning how good you can be at something with a 1 week course.

 

[e30ftw]

I have never seen an unrecognized esophageal intubation after the advent of prehospital EtCO2 monitoring. Never. In great systems with highly educated paramedics, available intubation rotations, an involved medical director, and good QA I'd say the rate is comparable (elite, competitive programs and flight EMS).

I've seen 3 respiratory codes 2/2 EMS tubing the goose in the past year, including 2 "clean kills" ie: pts w/o significant pathology other than being paralyzed with a tube in their esophagus.

one was a 20ish female intubated for "AMS" after an MVC which occured <5 min from the hospital who arrested 2/2 esophageal intubation and had normal trauma scans.

we have a very well-developed EMS system with a long history of involved medical directors, etc.

clean kills.

 

[OCDEMS]

I've seen 3 respiratory codes 2/2 EMS tubing the goose in the past year, including 2 "clean kills" ie: pts w/o significant pathology other than being paralyzed with a tube in their esophagus.

one was a 20ish female intubated for "AMS" after an MVC which occured <5 min from the hospital who arrested 2/2 esophageal intubation and had normal trauma scans.

we have a very well-developed EMS system with a long history of involved medical directors, etc.

clean kills.

I'm not saying it's impossible, just that I've never seen it post-EtCO2. Then again, where I worked, not using EtCO2 on EVERY intubation (including King Airway) could literally get you street time, if not fired. Regardless if there was a poor outcome. Even in the rare instances where EtCO2 was ineffective, from say copious vomiting, we were expected to "exhaust" all of our EtCO2 microstream lines before we could stop using it. Then, even after that, the standard was to auscultate (obviously) and visually confirm, again, with DL. Can't see it? Pull the tube, regardless of how "in" you think it was. Even then, the documentation was tremendous. Tubes had to be checked on exit of the ambulance and after transfer to the ED bed. Collars are placed on all intubations to prevent hyperextension of the neck. Honestly, confirming placement had become a sort of obsession in my service, because the consequence to the patient and the provider was so serious. Not properly confirming tube placement is a good way to get dressed down as a new medic, which is why the capnolines are literally everywhere in the ambulance.

I'm not trying to be difficult, but one of the most common causes of ET displacement, from my own observations, is ED staff. I've watched numerous ET tubes pulled out from overzealous transfer from stretcher to cot. RT or nurse is bagging and, suddenly and without warning, uncoordinated lateral transfer of the patient. Patient goes, bag stays in RT/nurse hand. Tube displaced. Same goes for pacing. I've seen patients lose a pulse because an overzealous ED nurse pulled the 3-lead. On our older monitors, this would immediately lead to cessation of pacing and loss of mechanical capture. Our ambulances were using EtCO2 probably 4 years before I saw it regularly used in the ED. Our ED now has a LUCAS because the EMS services started to have them. They're apparently very popular with the cath lab staff because most of the device is radiolucent. We got along with our ED staff, so no hard feelings. Just sayin'.

 

[medic25]

I'm not trying to be difficult, but one of the most common causes of ET displacement, from my own observations, is ED staff. I've watched numerous ET tubes pulled out from overzealous transfer from stretcher to cot. RT or nurse is bagging and, suddenly and without warning, uncoordinated lateral transfer of the patient. Patient goes, bag stays in RT/nurse hand. Tube displaced.

This is why we implemented an EMS airway protocol that includes having the ED confirm tube placement on the EMS stretcher prior to transfer. This way if the tube is dislodged during transfer the medic is in the clear and the staff know that it just occurred.

 

[pinipig523]

1st, don't get a great view, if it looks super good, pull back a bit. the close you are to the cords with the camera the less room to maneuver
2nd, don't pull the stylet yourself. rigid stylets in my experience pull the tube if you try to do it solo. Hold the tube in place and have someone else pull the stylet so you don't dislodge.
3rd don't go in like you normally would with the stylet, go in horizontally until the tube is near the cords, then flip your stylet vertical. this will usually end up inserting the tube right where you want it.
4th, addendum to 2nd: once the stylet is within the cords, it's hard to advance because It won't straighten. What you do is have someone hold your rigid stylet in place and you advance the tube forward.

The motor skills are different between VL and DL, you run into trouble when you assume it's the same.

Yes, if the view is too good to be true, it usually is. Pull back. You should have no more than half the vocal cords on the top of the video monitor.

 

[Arcan57]

I don't completely disagree with you, but I will say that there is significant controversy (at least among EMS providers) about the studies showing poor first-pass success. To your comment regarding BVM: there was a study in SCA and it found the BVM group had better neurologic outcomes. http://www.ncbi.nlm.nih.gov/pubmed/23321764. Good thought. With that said, the reasons for this probably vary. The Wang studies out of Pittsburgh have been criticized because they took place in PA, where EMS is largely rural and funded in all sorts of crazy, non-sustainable ways. Someone will argue with me, but it's largely true. In my own experience, I've rarely ever worked with anyone who had the lack of exposure that he described in one of his studies ( I think was 1-2 attempts/yr). Most of our paramedics obtained at least 5-6 intubations a year with overall success in the 90% range and a first-pass rate in the 80th percentile. Among experienced paramedics I would venture to say it was well over 90% and with higher total numbers. Not ED quality, admittedly. I have never seen an unrecognized esophageal intubation after the advent of prehospital EtCO2 monitoring. Never. In great systems with highly educated paramedics, available intubation rotations, an involved medical director, and good QA I'd say the rate is comparable (elite, competitive programs and flight EMS). Again, rare.

There is also some debate about the neurologic outcomes in intubation during SCA. I personally used to work in a system where intubation took priority in arrest and, honestly, I still believe it affected outcomes. Placing undue and unnecessary pressure for early success at the expensive of high-quality CPR is probably the causative agent of the poor outcomes, not the intubation itself. Only recently did the emphasis go to "high-performance" CPR and intubation before transport.

I definitely think you'll see adoption of ultrasound in well-funded systems, if only because I've already seen an entire industry starting to provide it. GE is already dabbling in the market and Physio, Zoll, and Philips wants to sell the next great thing. Capitalism will win here. Apparently, according to my old monitor rep, at least one manufacturer is already developing a future monitor with included ultrasound and there is a CE industry upstarting to provide 3 day and 1-week ultrasounds courses. As part of the new National Scope of Practice update from the old paramedic to the new, every paramedic in my system received a basic ultrasound in-service, including the basics of a FAST exam. I've read about systems that teach everything from the basics of kidney stone identification to fractures in the larger long bones. I'm not speaking to the efficacy of any of this, and as someone who recognizes there are entire fellowships in ultrasound, I myself questioning how good you can be at something with a 1 week course.

I was actually speaking of a study of VL vs. BVM, I was aware that the existing literature has favored BVM vs. DL. Preferably the study would take all comers, since if pre-hospital intubation is saving lives I think that the small numbers and dismal prognosis of SCA would make a properly powered study prohibitively expensive.

In regards to U/S, the systems that would benefit from more pre-hospital advanced technology are also the systems that are going to have the most difficult time getting the reps to maintain competency. 3-10 days of U/S is going to show you just enough to make you dangerous.

 

[Mighty Mouse]

I used to be incredibly frustrated with glidescope because I would get a view of cords, but couldn't flip the friggin tube into the airway. What I have learned is that its all about getting the cords into the center of the screen. If you see the cords perfectly, but they're at the top 1/3 of the screen, dexterity-wise that will translate into a difficult flipping mechanism. But, despite being taught in residency that I don't have to pull up on the glidescope blade, I gently pull up, the cords move the center of the screen, and I have been 100% pass rate ever since. I don't tube without it now except for the rare occasion where I decide to go blade just to prove I still can.

Had a difficult airway (aspiration of 2+ liters of gastric content, apnea, and code -- tubing during CPR) this week at one of the shops where the glidescope is actually from the OR and everyone thinks I'm nuts when I ask for it. They tried to load the tube with a normal stylet for me while they searched frantically for the rigid one. The normal malleable stylet makes it substantially harder to pass. Nobody could find the stylet, so I went back to traditional Mac 4 and was able to get the airway with no issue. Agree -- important to feel confident with both techniques, but knowing you can snag any airway with a glidescope is huge. Used to be as a resident when I missed with traditional blade and went to glidescope I already thought I was screwed. Now I know I'll get it. And I understand how other adjuncts like positioning and boogies will help you too -- but my shop has boogies that are more like foley catheters than the rigid ones with the cudet tip. They suck.

I basically tube with total ease now with the scope and every time I think to myself (or say out loud to the room) -- this is the sexiest damn machine I've ever seen.

 

[RustedFox]

Thanks for the tips all. The only sentiment I'm having discordant thoughts about is the rigid stylet and the tube. I could not pass that thing anywhere near the cords on the viewscreen. Plastic of the scope handle in the way. Practice, I guess.

 

[gman33]

I'm not sure the exact reason why, but the rigid stylet is easier to pass when you hold it towards the distal end.
Probably some geometry reason if I really thought about it.

I love the glidescope, but it is a different skill.

 

[Arcan57]

Thanks for the tips all. The only sentiment I'm having discordant thoughts about is the rigid stylet and the tube. I could not pass that thing anywhere near the cords on the viewscreen. Plastic of the scope handle in the way. Practice, I guess.

Advance the blade less far into the oropharynx. With the glidescope, where the scope is determines the success of intubation not how you manipulate the ETT. It's like a bombing run, once you've started passing it down midline it's going to end up where it ends up. The only adjustment you can (and should make) is to crank your wrist up to get the cords to move from top of the screen to middle. This is the exact move they told you not to do with DL because with a metal blade it leads to spitting chiclets.

 

[goodoldalky]

It's hard to talk about VL technique without seeing it but I bet when you attempted to intubate you held the ETT about halfway down the tube in similar fashion to DL. If you do this you get the exact problem you describe and you'll feel like you need to bend the stylet or other nonsense. You need to hold the ETT from the very top when using VL or you won't be able to maneuver it around the posterior oropharynx. The best way to describe it would be to hold it more like a stick shift in a car for VL and less like a pencil as you do with DL. Tough to explain though. Good luck.

 

[Bostonredsox]

When I first started with VL I had trouble with the stylets too. What I did was get a view, throw a pocket bougie in and then tube over the bougie. I still do this occasionally in mouths that don't open fully but this is rare as I know how to manipulate the stylet now. But anyway it will help you get the tube in if your having trouble with the stylet. Bougie always slides in nice.

 

[southerndoc]

Yep.

Granted, I've only used it a handful of times, but we have the plastic videoscope blade and then the totally detached screen that's 'held' by another individual, or just placed on the bedside. Screen is okay, but the tube over the manufacturer-provided stylet.... garbage. Can't manipulate it anywhere, can't bend it as you go, its rigid as all hell and pulls the tube out along with it when you try to pull the stylet to connect the BVM.... aerwu9paodsica;lcn.

This is largely just me complaining. Feel free to comment/criticize.

Are you sure you're using the stylette correctly? It's not advanced to the trachea like a typical stylette (you insert it with the tip curved toward the right side of the mouth, go down to the trachea, then rotate it). When you get to the vocal cords, you hold the stylette in place with your thumb while using your hand to advance the tube. The stylette stays in the same position. You don't pull the stylette out of the tube until you advance the tube a little off the stylette. It takes practice, but once you get it, it's pretty easy. I've never had any problems once I learned how to correctly use the stylette. I do it with one hand (without anyone holding the stylette). Use the Glidescope both for difficult airways and occasionally just for practice.

 

[Droperidol]

A decent video on the ideal use of the glidescope for those that can't visualize - http://airway.jems.com/2011/03/glidescope-4-step-technique-tutorial/

My main issue is that it is rather difficult to be a one man operator with the Glidescope. Levitan at TCEP showed us a way to potentially get around this. Once you have your view on the scope and have inserted the tube and stylet in the mouth. Get the tip just inside the cords. Next, use your thumb to pop up the rigid stylet and put the tube and glidescope in your left hand. This leaves your right hand free and you can slide the ETT down and simultaneous slide the rigid stylet out with a scissoring motion of your right hand. Once your in several cm, you can go ahead and just pull out the stylet. No need for RT if you do this right and they won't pop your tube out of the trachea.

 

[Janders]

You need to practice more before you use it live. Glidescope technique is NOT DL technique with a video screen.
*You put the glidescope down the middle of the mouth, not down the right to push the tongue out of the way
*You do not necessarily need to pull up, as you do with DL, to visualize the cords
*Often people go for a very zoomed in view of the cords, middle of the screen. Instead, try a zoomed-out view, with the cords in the top left corner of the screen. This gives you a much earlier view of the tip of the ETT/stylet, so you can guide it into place more easily
* hold the rigid, glidescope stylet all the way in the back, where it has a handle. Very different from DL. Then make a motion like you are pulling a slot machine in Vegas. This circular motion with push the tip of the tube UP into the cords.
*Alternatively, insert the tube from the side of the mouth, basically held in the same plane as the patient's clavicle. Then, you can TWIST the tube, triggering the tip to either rotate up or down. I LOVE this trick, but it is hard for me to explain it in writing. Much better in video. *what a transition*

Watch this video. Just trust me. It is free. It is great. I shows cut away mannequins being intubated using different techniques and tools, with side-view, operator-view, and video-view of every technique. It is FULL of great tips. Free on iTunes. It is EMCrit Podcast 73 -- Airway Tips with Jim DuCanto. 30 minutes. TOTALLY worth it. Watch it on the treadmill. My last bulletpoint is shown around minute 12.

http://emcrit.org/podcasts/james-ducanto-airway-tips/

 

[Arcan57]

For those of us that trained prior to the debate about whether to teach VL only or VL w/ DL back-up, it's probably worth paying the money and time to do one of the airway courses and get in the reps on VL. If you're reaching for VL as a back-up after failed DL (which I think is what a lot of us that graduated before 2010 are doing), you need to have your VL skills down since adrenaline and deteriorating conditions are going to limit your problem solving abilities in the moment.

 

[RustedFox]

Are you sure you're using the stylette correctly? It's not advanced to the trachea like a typical stylette (you insert it with the tip curved toward the right side of the mouth, go down to the trachea, then rotate it). When you get to the vocal cords, you hold the stylette in place with your thumb while using your hand to advance the tube. The stylette stays in the same position. You don't pull the stylette out of the tube until you advance the tube a little off the stylette. It takes practice, but once you get it, it's pretty easy. I've never had any problems once I learned how to correctly use the stylette. I do it with one hand (without anyone holding the stylette). Use the Glidescope both for difficult airways and occasionally just for practice.

Yeah, I wasnt' using it AT ALL correctly. Would have had no idea if you, and the other posters wouldn't have said something.

Wow.

 

[deleted92121]

We use VL frequently on the trucks and in my ED. Now I know as a medic I don't tube as much as the docs though I have had a record year and have done 21 this year. All have been using VL and have a 100% success rate (not bragging, just a good year with no real tough airways). My only tips are don't insert the blade too far for better visualization and don't use the rigid stylet. I switched to using a standard flexible stylet and have had a much easier time. I bend it slightly, not quite a 90 degree angle and have had a much easier time with it.

 

[Bostonredsox]

For those of us that trained prior to the debate about whether to teach VL only or VL w/ DL back-up, it's probably worth paying the money and time to do one of the airway courses and get in the reps on VL. If you're reaching for VL as a back-up after failed DL (which I think is what a lot of us that graduated before 2010 are doing), you need to have your VL skills down since adrenaline and deteriorating conditions are going to limit your problem solving abilities in the moment.

Seconded. I did the ACEP difficult airway course a few months back and it was excellent. Highly recommend it. You get to spend a ton of time practicing with different devices and you pick up small tips and pointers from the instructors which I have found quite useful in practice.

 

[Perrin]

I had a WTF moment with our glidescope this evening.

Pt had severe COPD and progressed from NC to BiPAP to buying a tube. Attempted with a Mac, but airway was very anterior and I wasn't able to pull the epiglottis up enough to visualize the cords. No problem, I always pull the GS in the room when I'm tubing someone. I insert the GS and look at the screen. Everything looks wrong. The epiglottis is projecting from right to left. I maneuver the GS for a second look and same thing, the EG is at 90 degrees. I pull it out, let RT bag the patient while I re-seat the scope in the blade. It's in correctly, but the view on the screen is still rotated. I toss the GS and grab the Miller. No problem pulling up the epiglottis and visualize the tube through the cords on the first shot.

After the patient was stabilized, I got out the GS again. I pulled the scope out of the blade and looked at it. I couldn't see any defect in the scope or the blade and the picture on the screen was oriented correctly. I inserted it into the blade and the picture was now rotated again. I re-inserted the scope slowly into the blade and watched as it went through. The corner of the distal part of the scope was catching inside the blade and slowly twisting counter-clockwise at it slid through the blade. I pulled it out again and made sure I inserted it precisely into the blade, there was no rotation, and the picture was correctly oriented.

Learned 2 things,
1. Don't just look to make sure the video screen is showing a picture, verify the orientation is correct.
2. Technology is great, but when it fails, know how to do it the old fashioned way.

 

[Rendar5]

I've had that happen to me. I've also had old-fashioned technology fail on me before too. had a bulb in a Mac Blade burn out in the middle of a tube. had to open another blade and trade bulbs.

 

[Old_Mil]

If its a glidescope, put the tube on the manufacturer's stylet. Put the end of the tube in the patient's mouth right of midline next to the blade with the balance of the tube nearly horizontal and almost lying on the patients chest. With a lever action pull the tube towards you rotating the business end of the tube into the mouth, along the tongue, and into the airway as the lever action drives the tube anteriorly. You can almost tube people with your eyes closed doing this.

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